RESUMO
While many patients who present with dysphagia have a clinically identifiable cause of dysphagia, the etiology of swallowing difficulty is oftentimes a diagnostic enigma. The aim of this article is to review possible etiologies of dysphagia when objective evidence of dysphagia is lacking. Included in this discussion are cricopharyngeal spasm, retrograde cricopharyngeal dysfunction, muscle tension dysphagia, dysphagia secondary to medications, and functional dysphagia.
Assuntos
Transtornos de Deglutição , Humanos , Transtornos de Deglutição/diagnóstico , Transtornos de Deglutição/etiologia , Adulto , Músculos Faríngeos/fisiopatologia , Espasmo/diagnóstico , Deglutição/fisiologiaRESUMO
OBJECTIVES: The inability to burp, known as retrograde cricopharyngeal dysfunction (R-CPD), was initially described in adults. The proposed clinical diagnostic criteria for R-CPD include belching inability, abdominal bloating and discomfort/nausea, postprandial chest pain, and involuntary noises. Botulinum toxin injection to the cricopharyngeal muscle has been reported to be beneficial. High-resolution esophageal impedance-manometry (HRIM) features in adolescent patients with R-CPD have not been described yet. The aim of our study was to describe the clinical and HRIM findings of pediatric patients with R-CPD. METHODS: Clinical and manometric features of five pediatric patients diagnosed with R-CPD were reviewed. HRIM study protocol was modified to include the consumption of carbonated drink to provoke symptoms and distinctive manometric features. RESULTS: We report five female patients aged 15-20 years who presented with an inability to burp and involuntary throat sounds. HRIM revealed normal upper esophageal sphincter (UES) relaxation during swallowing, but abnormal UES relaxation with concurrent high esophageal impedance reflecting air entrapment and secondary peristalsis following the carbonated drink challenge. Four patients exhibited esophageal motility disorder. All patients reported improvement or resolution of symptoms after botulinum toxin injection to the cricopharyngeus muscle. CONCLUSIONS: Adolescents with an inability to burp, reflux-like symptoms, bloating, and involuntary throat noises should be assessed for R-CPD by pediatric gastroenterologists with HRIM. The relatively recent recognition of this novel condition is the likely reason for its under- and misdiagnosis in children.
Assuntos
Impedância Elétrica , Manometria , Adolescente , Feminino , Humanos , Adulto Jovem , Deglutição , Transtornos de Deglutição/diagnóstico , Transtornos de Deglutição/fisiopatologia , Transtornos de Deglutição/etiologia , Transtornos da Motilidade Esofágica/diagnóstico , Transtornos da Motilidade Esofágica/fisiopatologia , Esfíncter Esofágico Superior/fisiopatologia , Manometria/métodos , Músculos Faríngeos/fisiopatologia , AdultoRESUMO
BACKGROUND: Swallowing dysfunction is a common dysfunction after stroke, and its incidence exceeds 50%. Aspiration pneumonia and malnutrition induced by dysphagia not only cause psychological shock to patients after stroke, but also burden the medical payment. Neuromuscular electrical stimulation, which stimulates the cortex and cortical bulb pathways to improve swallowing function, has been one of the emerging treatments for the post-stroke deglutition disorder. These therapy operators require the proficiency in professional knowledge, limiting clinical large sample studies, so there is an absence of evidence-based medicine. The research is to evaluate the effectiveness of neuromuscular electrical stimulations combined with swallowing-related muscle training to treat swallowing dysfunction after stroke. METHODS: Computer retrieval performed in the 9 databases, including PubMed, Embase, Web of science, Cochrane Library, ClinicalTrials, China Biomedical Literature Database (CBM), China Knowledge Network Database (CNKI), Wanfang Database (WanFang), and China VIP Database (VIP). Taking the published literature from the establishment of the database until December 20, 2020. Literature searching is related to neuromuscular electrical stimulation randomized controlled trials on the effect of swallowing in stroke. In addition, we will do the manual search in Baidu Academic and Google Academic database as a supplementary search. The correlative randomized controlled clinical studies retrieval time range from the establishment of the database to December 20, 2020. Two investigators will screen the literature according to the inclusion and exclusion criteria independently, during that period they will evaluate the quality of the included studies and extract data from studies. The extracted data are dichotomous data will be represented by relative risk, continuous data will be represented by mean difference or standard mean deviation. If there exists heterogeneity and the final data summary analysis select random effect model. On the contrary, the fixed effect model is selected. Then, RevMan5.3 software was used when analyzing included literature. Meanwhile, the analysis results were illustrated by drawing. RESULTS: This review will summarize available trials aimed at providing a comprehensive estimation of effectiveness of neuromuscular electrical stimulation associated with swallowing muscle training for post-stroke dysphagia. CONCLUSION: This review based on a comprehensive analysis of currently published randomized controlled trials on post-stroke dysphagia, that provide reliable evidence-based medicine evidence for the efficacy of neuromuscular electrical stimulation associated with swallowing rehabilitation training. REGISTRATION NUMBER: INPLASY202110009.
Assuntos
Transtornos de Deglutição/terapia , Terapia por Estimulação Elétrica/métodos , Terapia Miofuncional/métodos , Reabilitação do Acidente Vascular Cerebral/métodos , Acidente Vascular Cerebral/complicações , Adulto , Idoso , Deglutição/fisiologia , Transtornos de Deglutição/etiologia , Feminino , Humanos , Masculino , Metanálise como Assunto , Pessoa de Meia-Idade , Músculos Faríngeos/fisiopatologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa , Acidente Vascular Cerebral/fisiopatologia , Revisões Sistemáticas como Assunto , Resultado do Tratamento , Adulto JovemAssuntos
Músculos Faciais/fisiopatologia , Doenças Neurodegenerativas/diagnóstico , Núcleo Olivar/patologia , Músculos Faríngeos/fisiopatologia , Tremor/fisiopatologia , Eletromiografia , Feminino , Humanos , Hipertrofia/patologia , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Doenças Neurodegenerativas/patologia , Doenças Neurodegenerativas/fisiopatologia , Núcleo Olivar/diagnóstico por imagem , Tremor/diagnósticoRESUMO
OBJECTIVES: Obstructive sleep apnea (OSA) is characterized by repeated upper airway collapse while sleeping which leads to intermittent hypoxemia. Upper airway stimulation (UAS) is a commonly practiced modality for treating OSA in patients who cannot tolerate, or do not benefit from, positive airway pressure (PAP). The purpose of this study is to identify the effect of lateral pharyngeal collapse patterns on therapy response in UAS. METHODS: A retrospective cohort study from a single, tertiary-care academic center was performed. Patients who underwent UAS between October 2016 and July 2019 were identified and analyzed. Drug-induced Sleep Endoscopy (DISE) outcomes between Apnea-Hypopnea Index (AHI) responders and AHI non-responders were compared. Those with complete concentric collapse at the velopharynx were not candidates for UAS. RESULTS: About 95 patients that underwent UAS were included in this study. Pre- to Post-UAS demonstrated significant improvements in Epworth Sleepiness Scale (12.0 vs 4.0, P = .001), AHI (29.8 vs 5.4, P < .001) and minimum oxygen saturation (79% vs 83%, P < .001). No DISE findings significantly predicted AHI response after UAS. Specifically, multiple types of lateral pharyngeal collapse patterns did not adversely effect change in AHI or AHI response rate. CONCLUSION: Demonstration of lateral pharyngeal collapse on DISE, in the absence of complete concentric velopharyngeal obstruction, does not appear to adversely affect AHI outcomes in UAS patients. LEVEL OF EVIDENCE: VI.
Assuntos
Terapia por Estimulação Elétrica/métodos , Palato Mole/fisiopatologia , Músculos Faríngeos/fisiopatologia , Faringe/fisiopatologia , Apneia Obstrutiva do Sono/terapia , Idoso , Pressão Positiva Contínua nas Vias Aéreas , Feminino , Humanos , Hipofaringe/fisiopatologia , Laringoscopia , Masculino , Pessoa de Meia-Idade , Orofaringe/fisiopatologia , Prognóstico , Estudos Retrospectivos , Apneia Obstrutiva do Sono/fisiopatologia , Falha de Tratamento , Resultado do TratamentoRESUMO
OBJECTIVES: To identify and characterize subgroups of stroke patients with clinical signs of dysphagia, based on swallowing-related strength and skill impairments of the submental muscle group. DESIGN: Prospective observational study. SETTING: Inpatient rehabilitation centers and community dwellings. PARTICIPANTS: Individuals (N=114), including stroke patients with dysphagia (n=55) and 2 control groups including myopathic patients with dysphagia (n=19) and healthy volunteers (n=40) were included in this study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Novel clinical assessment of strength (force generation) and skill (spatial and temporal precision of muscle activation) of the submental muscle group during swallowing and nonswallowing behaviors, using surface electromyography and dynamometry. RESULTS: Hierarchical cluster analysis revealed 4 clusters, which could be broadly characterized as cluster 1: intact strength and skill, cluster 2: poor strength and poor nonswallowing skill, cluster 3: poor strength, and cluster 4: poor strength and poor swallowing skill. Membership in cluster was significantly associated with medical diagnosis (P<.001). The majority of healthy and myopathic participants were assigned to clusters 1 and 3, respectively, whereas stroke patients were found in all 4 clusters. Skill outcome measures were more predictive of cluster assignment than strength measures. CONCLUSIONS: Although healthy and myopathic participants demonstrated predominantly homogeneous swallowing patterns of submental muscle function within their etiology, several subgroups were identified within stroke, possibly reflecting different subtypes of swallowing function. Future research should focus on the nature and rehabilitation needs of these subtypes. Assessment of skill in swallowing may be an important but overlooked aspect of rehabilitation.
Assuntos
Transtornos de Deglutição/classificação , Transtornos de Deglutição/fisiopatologia , Força Muscular/fisiologia , Músculos Faríngeos/fisiopatologia , Acidente Vascular Cerebral/classificação , Acidente Vascular Cerebral/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Inquéritos e QuestionáriosRESUMO
Understanding the interactions between neural and musculoskeletal systems is key to identifying mechanisms of functional failure. Mammalian swallowing is a complex, poorly understood motor process. Lesion of the recurrent laryngeal nerve, a sensory and motor nerve of the upper airway, results in airway protection failure (liquid entry into the airway) during swallowing through an unknown mechanism. We examined how muscle and kinematic changes after recurrent laryngeal nerve lesion relate to airway protection in eight infant pigs. We tested two hypotheses: 1) kinematics and muscle function will both change in response to lesion in swallows with and without airway protection failure, and 2) differences in both kinematics and muscle function will predict whether airway protection failure occurs in lesion and intact pigs. We recorded swallowing with high-speed videofluoroscopy and simultaneous electromyography of oropharyngeal muscles pre- and postrecurrent laryngeal nerve lesion. Lesion changed the relationship between airway protection and timing of tongue and hyoid movements. Changes in onset and duration of hyolaryngeal muscles postlesion were less associated with airway protection outcomes. The tongue and hyoid kinematics all predicted airway protection outcomes differently pre- and postlesion. Onset and duration of activity in only one infrahyoid and one suprahyoid muscle showed a change in predictive relationship pre- and postlesion. Kinematics of the tongue and hyoid more directly reflect changes in airway protections pre- and postlesion than muscle activation patterns. Identifying mechanisms of airway protection failure requires specific functional hypotheses that link neural motor outputs to muscle activation to specific movements.NEW & NOTEWORTHY Kinematic and muscle activity patterns of oropharyngeal structures used in swallowing show different patterns of response to lesion of the recurrent laryngeal nerve. Understanding how muscles act on structures to produce behavior is necessary to understand neural control.
Assuntos
Deglutição/fisiologia , Músculos Laríngeos/fisiopatologia , Nervos Laríngeos/patologia , Músculos do Pescoço/fisiopatologia , Músculos Faríngeos/fisiopatologia , Animais , Fenômenos Biomecânicos/fisiologia , Eletromiografia , Fluoroscopia , SuínosRESUMO
RATIONALE: Mandibular position and motion during sleep rely on the balance between mandibular elevators and depressors. We hypothesized that vertical mandibular position (VMP) modulates airflow amplitude during sleep. METHODS: VMP, tidal nasal flow pressure (NFP) and concurrent surface electromyographic activity of the masseters (sEMG-m) were recorded and processed by a customized algorithm from 100 polysomnographic fragments including a micro-arousal (25 obstructive sleep apnea patients). The relationship between mandibular position and changes in airflow was analysed. RESULT: Concurrent VMP and sEMG-m activity changes routinely occurred before a new steady state of airflow documented by NFP. Vertical mandible depression was associated with a median (95% CI) reduction in NFP of 40.9% (14.6%-71.3%, pâ¯=â¯0.007) while vertical mandible elevation and mouth closure were associated with a median (95% CI) relative increase in NFP after arousal of 52.6% (17.9%-56.2%, pâ¯=â¯0.001). CONCLUSION: Elevation and lowering of the mandible were associated with changes in masseteric EMG activity modulating airflow amplitude during sleep.
Assuntos
Mandíbula/fisiologia , Músculos da Mastigação/fisiologia , Placas Oclusais , Músculos Faríngeos/fisiologia , Mecânica Respiratória/fisiologia , Apneia Obstrutiva do Sono/fisiopatologia , Adulto , Idoso , Estudos Transversais , Eletromiografia , Feminino , Humanos , Masculino , Mandíbula/fisiopatologia , Músculos da Mastigação/fisiopatologia , Pessoa de Meia-Idade , Músculos Faríngeos/fisiopatologia , Polissonografia , Estudos Prospectivos , Sono/fisiologia , Apneia Obstrutiva do Sono/reabilitaçãoRESUMO
Dropped head syndrome can be the presenting feature of a wide spectrum of neurological conditions. In this study, we aimed to define the clinical characteristics and treatment outcomes of 107 patients, where head drop was the presenting or predominant clinical feature of a myopathy. Median age at presentation was 68 years (range 42-88). A specific diagnosis was reached in 53% of patients: Inflammatory myopathy (nâ¯=â¯16), myopathy with rimmed vacuoles (nâ¯=â¯10), radiation-induced myopathy (nâ¯=â¯8), sporadic late-onset nemaline myopathy (nâ¯=â¯7), myofibrillar myopathy (nâ¯=â¯4), facioscapulohumeral dystrophy (nâ¯=â¯3), inclusion body myositis (nâ¯=â¯2), mitochondrial myopathy (nâ¯=â¯2), scleroderma-associated myopathy (nâ¯=â¯2), and single cases of necrotizing autoimmune myopathy, drug-induced myopathy, and B-cell chronic lymphocytic leukemia-myopathy. Splenius capitis had the highest diagnostic yield for a muscle biopsy (67%). When tested, 31/35 (89%) of patients had abnormal pulmonary function tests, 15/30 (50%) abnormal swallow evaluation, 24/65 (37%) abnormal electrocardiogram and 5/38 (13%) abnormal transthoracic echocardiogram. 23/43 (53%) treated patients responded to treatment. Patient-reported limb weakness and neck flexion weakness on physical examination were associated with good response to treatment. A wide spectrum of acquired and hereditary myopathies can present with head drop, some of which are potentially treatable. Establishing a diagnosis is crucial for timely treatment administration, screening for swallowing and cardiorespiratory involvement, and counseling regarding prognosis.
Assuntos
Doenças Musculares/diagnóstico , Doenças Musculares/fisiopatologia , Músculos do Pescoço/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Cabeça , Humanos , Masculino , Pessoa de Meia-Idade , Doenças Musculares/patologia , Músculos Paraespinais/patologia , Músculos Faríngeos/fisiopatologia , Músculos Respiratórios/fisiopatologiaRESUMO
BACKGROUND AND OBJECTIVE: Patients with oropharyngeal carcinoma (OPC) often have difficulty swallowing, which may affect quality of life (QoL). Radiation dose to constrictor muscles plays an important role. METHODS: 54 patients with locally advanced OPC were evaluated after intensity-modulated radiotherapy. Data were collected at standardized intervals using the EORTC questionnaires QLQ-C30 and QLQ-HN35 within two years. The pharyngeal constrictors (superior, middle, and inferior) were each contoured as an organ at risk. Influence of dose to the constrictors (≥55 Gy vs. <55 Gy) on late dysphagia and QoL was analyzed using the ttest. RESULTS: Late radiation-induced dysphagia depends significantly on the dose to the lower pharyngeal constrictor. At a dose of ≥55â¯Gy, 14 (64%) patients developed dysphagia grade ≤2 and 8 (36%) patients grade ≥3. At a dose of <55â¯Gy, the distribution at the end of radiotherapy (RT) was similar: 22 (69%) patients with dysphagia grade ≤2, 10 (31%) with grade ≥3. There was no dose-dependent difference in the severity of dysphagia in the acute phase (pâ¯= 0.989). There were differences 18 months after the end of RT: ≥55â¯Gy: 19 (86%) patients showed dysphagia grade ≤2; 3 (14%) grade ≥3. At <55â¯Gy, 31 (97%) patients developed grade ≤2, 1 (3%) grade ≥3 (18 months: p = 0.001; 24 months: pâ¯= 0.000). Late dysphagia is also dependent on the dose level of the middle constrictor muscle (6 months: pâ¯= 0.000; 12 months: pâ¯= 0.005, 18 months: pâ¯= 0.034). After 24 months, there was no significant difference (pâ¯= 0.374). CONCLUSION: Radiation dose to the upper constrictor muscle appears to be of little relevance. The middle and lower constrictor should be given special consideration to avoid late dysphagia. Long-term QoL is independent on radiation dose.
Assuntos
Carcinoma/radioterapia , Transtornos de Deglutição/etiologia , Neoplasias Orofaríngeas/radioterapia , Músculos Faríngeos/efeitos da radiação , Lesões por Radiação/etiologia , Radioterapia de Intensidade Modulada/efeitos adversos , Adulto , Idoso , Carcinoma/diagnóstico por imagem , Carcinoma/terapia , Quimiorradioterapia , Relação Dose-Resposta à Radiação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Órgãos em Risco , Neoplasias Orofaríngeas/diagnóstico por imagem , Neoplasias Orofaríngeas/terapia , Satisfação do Paciente , Músculos Faríngeos/diagnóstico por imagem , Músculos Faríngeos/fisiopatologia , Qualidade de Vida , Dosagem Radioterapêutica , Planejamento da Radioterapia Assistida por Computador , Inquéritos e Questionários , Fatores de TempoRESUMO
BACKGROUND: Head and neck surgeries can perturb normal structures of neck muscles and nerve innervations, which are supposed to function in harmony to allow complicated process like swallowing. It is still likely that cricopharyngal dysfunction emerges years after the head and neck surgeries. CASE PRESENTATION: We report a case with history of left unilateral vocal cord immobility and development of dysphagia and aspiration 2 years after radical thyroidectomy with neck lymph nodes dissection and medialization thyroplasty. Cricopharyngeal dysfunction was impressed and was confirmed with visualization of cricopharyngeal narrowing segment in radiographic contrast swallow examination. The patient was treated successfully by cricopharyngeal myotomy, achieving long-term relief in our 4 years of follow up. CONCLUSIONS: Our case of delayed cricopharyngal dysfunction after radical thyroidectomy and medialization thyroplasty shows that it is important to follow up swallowing functions after patients with UVCI undergo medialization thyroplasty. In the event of delayed manifestation of cricopharyngeal function, it can still be treated successfully by cricoharyngeal myotomy, achieving long term relief of dysphagia.
Assuntos
Transtornos de Deglutição/cirurgia , Traumatismos do Nervo Laríngeo/complicações , Miotomia/métodos , Esvaziamento Cervical/efeitos adversos , Músculos Faríngeos/cirurgia , Complicações Pós-Operatórias/cirurgia , Tireoidectomia/efeitos adversos , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/fisiopatologia , Feminino , Humanos , Traumatismos do Nervo Laríngeo/fisiopatologia , Traumatismos do Nervo Laríngeo/cirurgia , Pessoa de Meia-Idade , Músculos Faríngeos/inervação , Músculos Faríngeos/fisiopatologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologiaRESUMO
INTRODUCTION: In patients with OSA, substantial increases in genioglossus (GG) activity during hypopneas/apneas usually fail to restore normal airflow. The present study was undertaken to evaluate if this phenomenon can be explained by reduced activation of other peri-pharyngeal muscles. METHODS: We recorded EMGs of the GG and four other peri-pharyngeal muscles (accessory dilators, AD), in 8 patients with OSA and 12 healthy subjects, during wakefulness and sleep. Repetitive events of flow limitation were induced during sleep. The events with the highest increases in AD activity were evaluated, to assess if combined activation of both the GG and AD to levels higher than while awake ameliorate airflow reduction during sleep. RESULTS: Flow limitation triggered large increases in GG-EMG, but only modest augmentation in AD activity. Nevertheless, phasic EMG activity was present in 40 % of the ADs during sleep. In multiple events, increases of both GG and AD activity to levels substantially higher than while awake were not associated with improvement in airflow. CONCLUSIONS: We conclude that sleep-induced reduction in AD response to airway obstruction cannot completely explain the failure of upper airway dilators to maintain pharyngeal patency. We speculate that reduction in dilator muscle efficacy may be due to the alterations in motor units recruitment patterns during sleep.
Assuntos
Músculos Faríngeos/fisiopatologia , Mecânica Respiratória/fisiologia , Apneia Obstrutiva do Sono/fisiopatologia , Sono/fisiologia , Vigília/fisiologia , Adulto , Eletromiografia , Humanos , Masculino , Pessoa de Meia-Idade , Recrutamento Neurofisiológico/fisiologia , Adulto JovemRESUMO
Suprahyoid muscle activation and tongue pressure force play a critical role for swallowing function. In addition, dysphagia limit is one of most important factors indicating swallowing efficiency. The purpose of this study was to compare the effects of 8-week training sessions of three different exercises including chin tuck against resistance (CTAR), Shaker exercises and chin tuck exercise with theraband on suprahyoid muscle activity, anterior tongue pressure and dysphagia limit in healthy subjects. Thirty-six healthy volunteers aged between 18 and 40 years who scored below 3 points from Turkish version of Eating Assessment Tool (T-EAT-10) were included in the study, and all participants were divided into three groups randomly. Maximal suprahyoid muscle activations and dysphagia limit of participants were assessed by superficial electromyography. CTAR and chin tuck exercise with theraband increased the maximum suprahyoid muscle activation (p1 = 0.004, p2 = 0.018), whereas Shaker exercise did not increase maximal suprahyoid muscle activation (p = 0.507) after exercise training. CTAR and chin tuck exercise with theraband increased tongue pressure (p1 = 0.045, p2 = 0.041), while Shaker exercise did not increase anterior tongue pressure (p = 0.248). There was no statistically significant difference in dysphagia limits in three groups between before and after exercise training (p > 0.05). As a result, although CTAR seems to be the most effective exercise in most parameters, chin tuck exercise with theraband can also be used as an alternative to CTAR to improve suprahyoid muscle activity and tongue pressure.
Assuntos
Transtornos de Deglutição/terapia , Terapia por Exercício/métodos , Exercício Físico/fisiologia , Músculos Faríngeos/fisiopatologia , Língua/fisiologia , Adolescente , Adulto , Queixo , Deglutição , Transtornos de Deglutição/fisiopatologia , Eletromiografia , Feminino , Voluntários Saudáveis , Humanos , Osso Hioide/fisiopatologia , Masculino , Pressão , Turquia , Adulto JovemRESUMO
Cricopharyngeal dysfunction, especially cricopharyngeal achalasia, is a common cause of dysphagia, while patients with brainstem stroke and medullary damage have a relatively high risk of cricopharyngeal achalasia. The aim of this article was to introduce an improved method of CT-guided method of injecting botulinum toxin A into the cricopharyngeus muscle using esophageal balloon radiography, and to assess the effect of the botulinum toxin A injection on swallowing performance. Seventeen patients with cricopharyngeal dysphagia were treated with botulinum toxin A injection using esophageal balloon radiography combined with CT guidance to the cricopharyngeal muscle. Primary outcome measures, including Functional Oral Intake Scale and Deglutition Handicap Index, were performed at baseline, 1 week, and 1 month after treatment. The Levene method was used to test the homogeneity of variance, and the Kruskal-Wallis test was used to compare the scores between the timepoints. Botulinum toxin A injection resulted in obvious improvement in 15 patients (88.2%) and no improvement in two patients (11.8%). Compared with the scores prior to treatment, the Functional Oral Intake Scale and Deglutition Handicap Index scores were significantly improved at 1 week (P < 0.001 and P = 0.008, respectively) and 1 month after the treatment (P = 0.001 and P < 0.001, respectively). Thus, CT-guided percutaneous injection of botulinum toxin A is probably a relatively safe, well-tolerated, and viable technique for the treatment of cricopharyngeal dysphagia caused by brainstem injury. Localization with a balloon radiography made the needle guidance easier to visualize.
Assuntos
Toxinas Botulínicas Tipo A/administração & dosagem , Transtornos de Deglutição/tratamento farmacológico , Injeções Intramusculares/métodos , Fármacos Neuromusculares/administração & dosagem , Tomografia Computadorizada por Raios X/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Tronco Encefálico/lesões , Cateterismo/instrumentação , Deglutição , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/fisiopatologia , Esfíncter Esofágico Superior/diagnóstico por imagem , Esfíncter Esofágico Superior/fisiopatologia , Esôfago/diagnóstico por imagem , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Músculos Faríngeos/diagnóstico por imagem , Músculos Faríngeos/fisiopatologia , Resultado do Tratamento , Adulto JovemRESUMO
The distribution of muscle weakness in myasthenia gravis (MG) patients with acetylcholine receptor (AChR) antibodies is highly variable. As muscle groups respond differently to therapeutic interventions, it is important to acknowledge this variability. We analysed the distribution of muscle weakness in 225 AChR MG patients over time. On the basis of combinations of muscle weakness, seven phenotypes were defined: 'ocular' (O), 'bulbar' (B), 'neck/limbs/respiratory' (NLR), or a combination (O+B, O+NLR, B+NLR and O+B+NLR). MG remained restricted to ocular weakness in 5%, whereas 7% never had ocular weakness. At last follow-up, ocular or bulbar weakness had resolved more frequently than NLR weakness (40%, 38% and 25%; p = 0.003, respectively). Patients with O, B or OB phenotype at baseline had a higher age at onset and were more frequently male than patients with NLR, ONLR, BNLR or OBNLR phenotype (52.7⯱â¯17.5â¯vs. 44.0⯱â¯18.9; pâ¯=â¯0.007 and 64% vs. 37%; pâ¯=â¯0.002, respectively). MG patients have heterogeneous distributions of muscle weakness and frequently shift between phenotypes. The phenotypic variations found in AChR MG suggest that also other factors aside from the AChR antibody mediated immune response are of importance in determining the disease expression in MG.
Assuntos
Músculos da Mastigação/fisiopatologia , Debilidade Muscular/fisiopatologia , Miastenia Gravis/fisiopatologia , Músculos do Pescoço/fisiopatologia , Músculos Oculomotores/fisiopatologia , Músculos Faríngeos/fisiopatologia , Músculos Respiratórios/fisiopatologia , Adulto , Idade de Início , Idoso , Blefaroptose/etiologia , Blefaroptose/fisiopatologia , Inibidores da Colinesterase/uso terapêutico , Estudos de Coortes , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/fisiopatologia , Diplopia/etiologia , Diplopia/fisiopatologia , Progressão da Doença , Disartria/etiologia , Disartria/fisiopatologia , Extremidades , Músculos Faciais/fisiopatologia , Feminino , Glucocorticoides/uso terapêutico , Humanos , Imunossupressores/uso terapêutico , Masculino , Mastigação , Pessoa de Meia-Idade , Debilidade Muscular/etiologia , Músculo Esquelético/fisiopatologia , Miastenia Gravis/complicações , Miastenia Gravis/tratamento farmacológico , Fenótipo , Prednisona/uso terapêutico , Estudos Prospectivos , Brometo de Piridostigmina/uso terapêuticoRESUMO
As amyotrophic lateral sclerosis (ALS) progresses, dysphagia gets worse due to the weakening of pharyngeal musculature. As oral feeding becomes more difficult or dangerous due to worsening dysphagia, tracheal aspiration, or undernutrition, the necessity for tube feeding becomes increasingly important. This study aims to establish a standard pressure point by applying pharyngeal pressure using high-resolution manometry (HRM) to start tube feeding in patients with ALS.This study was designed as a retrospective analysis of prospectively collected data. Forty-one patients with ALS and 20 healthy subjects were participated. Both groups were evaluated using HRM, videofluoroscopic swallowing study (VFSS), and pulmonary function test. The swallowing pressure along the velopharynx (VP), tongue base (TB), pre-upper esophageal sphincter (UES), lower pharynx, and cricopharyngeus, as well as minimal UES pressure were measured using HRM.There was significantly positive correlation between the pressure of cricopharyngeus and forced expiratory volume in 1 second (FEV1). And there were significant correlations between results of VFSS and FEV1, FEV1%, forced vital capacity (FVC), and FVC%. There was a significant difference in the pressure of TB and cricopharyngeus between the control group and the ALS patient group. The pressures of VP, TB, lower pharynx, and cricopharyngeus have a significant correlation with the recommended feeding type by VFSS.Because it is possible to use HRM to quantitatively assess pharyngeal and respiratory weaknesses and it is more sensitive than other evaluation tools, the cutoff value of HRM parameters may be used to decide the feeding type in patients with ALS.
Assuntos
Esclerose Lateral Amiotrófica/fisiopatologia , Sistemas de Apoio a Decisões Clínicas , Transtornos de Deglutição/fisiopatologia , Métodos de Alimentação , Manometria/métodos , Idoso , Esclerose Lateral Amiotrófica/complicações , Esclerose Lateral Amiotrófica/terapia , Deglutição , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/terapia , Estudos de Viabilidade , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Pessoa de Meia-Idade , Músculos Faríngeos/fisiopatologia , Pressão , Estudos Prospectivos , Estudos Retrospectivos , Língua/fisiopatologiaRESUMO
Obstructive sleep apnea (OSA) is a chronic and common adult disorder characterized by recurrent episodes of upper-airway obstruction and reopening during sleep. OSA is associated with intermittent hypoxia, sympathetic overactivity, oxidative stress and high cardiovascular mortality and morbidity. It is known to be more common in men than women, partly due to differences in anatomy and functional respiratory components. There are also gender differences in reported symptoms, leading to potential under-diagnosis in females. This gender difference tends to decrease after menopause, demonstrating a role of menopausal status itself in OSA phenotypes. Aging, fat mass distribution, sex hormones and upper-airway collapsibility are postulated to play a major role in these findings. This review focuses on the most recent studies exploring gender differences in the prevalence, pathogenesis and clinical features of OSA. It discusses the role of menopause in this, and explore the underlying pathophysiological mechanisms.
Assuntos
Menopausa/fisiologia , Apneia Obstrutiva do Sono/epidemiologia , Adiposidade , Fatores Etários , Feminino , Hormônios Esteroides Gonadais/sangue , Humanos , Músculos Faríngeos/fisiopatologia , Prevalência , Índice de Gravidade de Doença , Fatores Sexuais , Apneia Obstrutiva do Sono/fisiopatologiaRESUMO
Purpose This study predicts and simulates the function and relative contributions of the intravelar and extravelar portions of the levator veli palatini (LVP) and palatoglossus (PG) muscles in velic constrictions. Method A finite element-based model of the 3-dimensional upper airway structures (palate, pharynx, tongue, jaw, maxilla) was implemented, with LVP and PG divided into intravelar and extravelar portions. Simulations were run to investigate the contributions of these muscles in velopharyngeal port (VPP) closure and constriction of the oropharyngeal isthmus (OPI). Results Simulations reveal that the extravelar portion of LVP, though crucial for lifting the palate, is not sufficient to effect VPP closure. Specifically, the characteristic "bulge" appearing in the posterior soft palate during VPP closure ( Pigott, 1969 ; Serrurier & Badin, 2008 ) is found to result from activation of the intravelar portion of LVP. Likewise, the intravelar portion of posterior PG is crucial in bending the "veil" or "traverse" ( Gick, Francis, Klenin, Mizrahi, & Tom, 2013 ) of the velum anteriorly to produce uvular constrictions of the OPI ( Gick et al., 2014 ). Conclusions Simulations support the view that intravelar LVP and PG play significant roles in VPP and OPI constrictions.