Effects of Device-Facilitated Lingual Strengthening Therapy on Dysphagia Related Outcomes in Patients Post-Stroke: A Randomized Controlled Trial.

BACKGROUND: Swallowing impairments resulting from stroke have few rehabilitative options. Prior evidence suggests lingual strengthening exercise may provide some benefit, but more randomized controlled trials are required. The purpose of this study was to examine efficacy of progressive lingual resistance training on lingual pressure generative capacity and swallowing outcomes for individuals with dysphagia after stroke. METHODS: Participants with dysphagia within 6 months of acute stroke were randomly assigned to: (1) treatment: progressive resistance tongue exercise using pressure sensors for 12 weeks with usual care; or (2) control: usual care only. Outcomes were measured at baseline, 8 and 12 weeks to assess group differences in lingual pressure generation, swallow safety, efficiency, oral intake, and swallowing quality of life. RESULTS: Final sample included 19 participants [treatment (N = 9) and control (N = 10)] with 16 males and 3 females (mean age = 69.33). Functional Oral Intake Scale (FOIS) scores improved significantly (p = 0.04) in the treatment group from baseline to 8 weeks compared to usual care (control). No significant differences between treatment groups were identified for other outcomes; large effect sizes were detected for group differences in lingual pressure generative capacity from baseline to 8 weeks at the anterior sensor (d = .95) and posterior sensor (d = 0.96), and vallecular residue of liquids (baseline to 8-week d = 1.2). CONCLUSIONS: Lingual strengthening exercise resulted in significant improvements in functional oral intake for patients with post-stroke dysphagia as compared to usual care after 8 weeks. Future studies should include a larger sample size and address treatment impact on specific aspects of swallow physiology.

Relationship Between Tongue Base Region Pressures and Vallecular Clearance.

Tongue base pressures have been thought to provide primary bolus clearance through the pharynx during swallowing. The relationship between bolus driving pressures and residue remaining in the valleculae after the swallow has not been defined. Thirty-seven dysphagic patients who were evaluated with both videofluoroscopy (VFSS) and high-resolution manometry (HRM) were identified within the University of Wisconsin Voice and Swallowing Outcomes database. Patients were categorized according to binary ratings of presence or absence of vallecular stasis as well as incomplete or complete tongue retraction on VFSS. Tongue base region pressures measured with HRM during saline swallows of 1 and 10 ml volumes were compared to ratings of vallecular stasis or tongue base retraction. No significant difference could be identified among mean peak HRM pressures when compared to presence or absence of vallecular stasis (1 ml saline: p = .1886; 10 ml saline: p = .7354). When categorized according to complete or incomplete tongue retraction, mean peak HRM pressures were significantly greater in the complete tongue retraction group as compared to incomplete tongue retraction (1 ml saline: p = .0223; 10 ml saline: p = .0100). Findings suggest there are multiple factors that lead to reduced vallecular clearance. In the absence of HRM measures, judging complete or incomplete tongue retraction on VFSS may be a more valid gauge of tongue base region pressures than vallecular clearance when planning dysphagia treatment.

Implementation of high-resolution manometry in the clinical practice of speech language pathology.

Visual imaging modalities, videofluoroscopic swallow study (VFSS) and fiberoptic endoscopic evaluation of swallow, for assessment of oropharyngeal dysphagia have been part of the speech language pathologist's (SLPs) armamentarium for the diagnosis and treatment of dysphagia for decades. Recently, the addition of high-resolution manometry (HRM) has enabled the SLP to evaluate pharyngeal pressures and upper esophageal sphincter relaxation. Taken together, the use of visual imaging modalities with HRM can improve interpretation of swallowing physiology and facilitate more effective treatment planning. The goal of this article is to describe a clinical paradigm using HRM as an adjunct to VFSS, by the SLP, in the assessment of complex dysphagia. Moreover, in three cases described, the value of manometric measurements in elucidating swallowing imaging studies and documenting physiologic change in response to treatment is highlighted. As technology in this area is evolving, so will the clinical use of HRM by the SLP. Limitations of current HRM systems and applications are discussed.

Speech pathologist practice patterns for evaluation and management of suspected cricopharyngeal dysfunction.

Speech pathologists are often the first professionals to identify signs of a cricopharyngeal (CP) dysfunction and make recommendations for further care. There are many care options for patients with CP dysfunction, but it is unclear how certain interventions are used in practice. A paper-based survey employing two clinical cases involving suspected CP dysfunction (Case 1 with adequate pharyngeal strength and Case 2 with coexisting pharyngeal weakness) was sent to members of American Speech-Language Hearing Association's Special Interest Group 13. Respondents ranked the order of management approaches (swallowing therapy, further evaluation, and referral to another medical professional) and selected specific interventions under each approach that they would recommend for each case. Completed surveys from 206 respondents were entered into analysis. The majority of the respondents recommended swallowing therapy as a first approach for each case (Case 1: 64 %; Case 2: 88 %). The most prevalent swallowing exercises recommended were the Shaker (73 %), effortful swallow (62 %), and Mendelsohn maneuver (53 %) for Case 1 and effortful swallow (92 %), Shaker (84 %), and tongue-hold swallow (73 %) for Case 2. 76 % of respondents recommended a referral for Case 1, while 38 % recommended the same for Case 2. Respondents with access to more types of evaluative tools were more likely to recommend further evaluation, and those with access to only videofluoroscopy were less likely to recommend further evaluation. However, the high degree of variability in recommendations reflects the need for best practice guidelines for patients with signs of CP dysfunction.

Dysphagia Profiles Among Inpatients with Dementia Referred for Swallow Evaluation.

BACKGROUND: Alzheimer's disease and related dementias (ADRD) patients who are hospitalized often develop oropharyngeal dysphagia, increasing risk for adverse outcomes, such as aspiration pneumonia. However, prevalence estimates of dysphagia are highly variable and often based on patient report or clinical testing rather than visualization of the swallow. OBJECTIVE: The aims of this study were to determine prevalence and severity of dysphagia among inpatients with ADRD referred for swallowing evaluation. METHODS: Electronic health record (EHR) abstraction of ADRD diagnosis and presence and severity of clinically-determined dysphagia on bedside swallow evaluation (BSE) and videofluoroscopic swallow study (VFSS). RESULTS: 16% (n = 268) had an ADRD diagnosis or were taking dementia-specific medication based on the EHR. 75% (n = 202) were diagnosed with dysphagia on the BSE. 60% subsequently underwent VFSS (n = 122) with dysphagia confirmation in 92% (n = 112). ADRD inpatients were significantly more likely to be diagnosed with dysphagia based on the BSE (p < 0.0001) than those without ADRD. Additionally, dysphagia on the VFSS was more severe in the ADRD group (p < 0.03). DISCUSSION: ADRD individuals may be vulnerable to developing or worsening dysphagia during hospitalization. Results underscore the importance of evaluating swallowing function in hospitalized patients with ADRD in order to facilitate targeted intervention.

Pressure abnormalities in patients with Zenker's diverticulum using pharyngeal high-resolution manometry.

OBJECTIVES: Zenker's diverticulum is associated with reduced cricopharyngeal compliance and abnormal intrabolus pressure. However, it is unclear how the pharynx compensates for these deficits. Developments in manometric technology have improved our ability to capture pharyngeal pressure events. This study aims to describe the pharyngeal-upper esophageal sphincter (UES) pressure profile during swallowing in patients with Zenker's diverticulum. METHODS: High-resolution manometry was performed on 11 patients with symptomatic Zenker's diverticulum and 11 age- and sex-matched healthy controls during 10 mL liquid swallowing tasks. Pharyngeal and UES pressure magnitudes, durations, and integrals were compared between patients and controls using independent t tests. Other manometric parameters, including residual UES pressure at the time of maximum tongue base pressure and pharyngeal-UES pressure gradient, were also evaluated. A case example using three-dimensional high-resolution manometry is presented. RESULTS: Compared with healthy controls, patients with Zenker's diverticulum exhibited pressure abnormalities in the UES region. While baseline and pre-opening maximum pressures were not different, residual pressures were elevated (P = .001). Pharyngeal-UES pressure gradients did not differ between the two groups. CONCLUSION: This study used high-resolution manometry to characterize pharyngeal pressure dynamics in patients with Zenker's diverticulum. The changes occurring at the cricopharyngeus appear to result in persistent UES pressurization during UES opening, rather than high tonic resting pressure. Pharyngeal-UES pressure gradients, critical to bolus passage, were also preserved in this patient population. LEVEL OF EVIDENCE: 3b.

Safety and Tolerability of Pharyngeal High-Resolution Manometry.

Purpose Pharyngeal high-resolution manometry is an emerging practice for diagnosis of swallowing disorders in the upper aerodigestive tract. Advancement of a catheter through the upper esophageal sphincter may introduce safety considerations. There are no published studies of catheter placement complications, side effects, or tolerability. This study examines patient-reported side effects and tolerability of pharyngeal high-resolution manometry. Method Data were collected prospectively from 133 adult patients who underwent pharyngeal high-resolution manometry for the 1st time. Patients rated tolerability specific to "nose" and "throat" using a visual analog scale for 4 procedure time points: catheter passage, during the procedure, catheter removal, and after the procedure. Complications during catheter passage and removal were recorded. A telephone call was placed to the patient within 6 days to survey side effects experienced after the procedure. Results The patient sample was composed of 91 males and 42 females with a mean age of 66 years ( SD = 14.4). Tolerability scores for catheter passage showed no significant difference ( p = .7288) in the nose versus throat. Tolerability for females was significantly less ( p = .0144) than that for males. Participants with the shortest procedure duration showed greatest discomfort in the nose ( p = .0592) and throat ( p = .0286). Complications included gag response (14%), emesis (2%), and epistaxis (< 1%). Side effects included sore throat (16%), nose discomfort (16%), coughing (11 %), nosebleed (4%), and nausea/vomiting (4%). Conclusions High-resolution manometry appears to have high patient tolerability with low incidence of side effects. Rates of complications and side effects are similar to those reported for other transnasal procedures.

Swallowing outcomes after cricopharyngeal myotomy: A systematic review.

BACKGROUND: No practice guidelines have been established for swallowing outcomes after cricopharyngeal myotomy (CPM). The purpose of this systematic review was to summarize evidence for swallowing outcomes in patients undergoing CPM to treat symptomatic cricopharyngeal dysfunction, in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) protocol. METHODS: Swallowing outcomes examined included penetration/aspiration ratings, manometric measures, patient-rated dysphagia scales, clinician-rated dysphagia scales, diet level, and weight. RESULTS: Three databases were queried for studies published between January 1995 and July 2015, resulting in a total of 122 full-text eligible records. Studies were screened and reviewed, culminating in 10 studies meeting inclusion criteria. Critical appraisal of study design, swallowing outcomes measures, and statistical analysis were summarized. CONCLUSION: This systematic review revealed insufficient evidence for guiding clinical practice. Future investigations should use validated patient-rated and clinician-rated instruments as well as detailed high-resolution manometry measures to optimally capture postoperative swallowing outcomes.