Biofeedback Training Improves Swallowing in a Unique Case of Upper Esophageal Sphincter Hypotonicity.

Hypotonicity of the upper esophageal sphincter (UES) has been reported only two times previously in the literature, with no reports of treatment options for this rarity. We present a third case of hypotonic UES found during high-resolution pharyngeal manometry. Although the patient had nearly absent resting pressures of the UES, pressures during and post-swallow were normal. It was hypothesized that the patient might be able to increase pre-swallow UES pressure using biofeedback. Using a chin up/out maneuver during manometry, the patient was able to achieve a more normal swallow pressure pattern. This case also highlights the need to complete manometry alongside other swallow imaging techniques for effective treatment planning and patient outcomes. Laryngoscope, 131:E1567-E1569, 2021.

[Effect of electronic moxibustion on activity of parapharyngeal wall in patients with achalasia of cricopharyngeus muscle after stroke based on musculoskeletal ultrasound].

OBJECTIVE: To observe the clinical effect of electronic moxibustion on dysphagia in patients with achalasia of cricopharyngeus muscle after stroke. METHODS: Sixty patients with dysphagia of achalasia of cricopharyngeus muscle were randomly divided into an observation group and a control group, 30 cases in each group. One patient in the observation group and 2 cases in the control group dropped off. The patients in the control group were treated with routine medical treatment, acupuncture treatment and swallowing rehabilitation training; the patients in the observation group were additionally treated with electronic moxibustion at Lianquan (CV 23), Tiantu (CV 22), Tianding (LI 17) and Futu (LI 18), 30 min each treatment. Both groups were treated 5 times a week for 4 weeks. The musculoskeletal ultrasound (MSUS) was applied to test the activity of parapharyngeal wall and the dysphagia score of Ichiro Fujishima was compared before and after 4-week treatment. RESULTS: After treatment, the activity of the parapharyngeal wall and the dysphagia score of Ichiro Fujishima were increased in both groups (P<0.01, P<0.05). The changes of activity of parapharyngeal wall and dysphagia score of Ichiro Fujishima in the observation group were greater than the control group (P<0.05, P<0.01). CONCLUSION: Electronic moxibustion can improve the impaired swallowing function and reconstruct the normal swallowing process.

Effortful swallow with resistive electrical stimulation training improves pharyngeal constriction in patients post-stroke with dysphagia.

This study aimed to evaluate the effect of effortful swallow combined with surface electrical stimulation as a form of resistance training on pharyngeal constriction function in post-stroke patients with dysphagia. Nineteen patients post-stroke with dysphagia received 20 min effortful swallow training with resistive electrical stimulation for 5 days per week for 4 weeks. Electrical stimulation was applied on the infrahyoid area as resistance against hyoid elevation. Stimulation intensity was adjusted daily up to the maximum tolerable level of the participant. Blinded biomechanical measurements of the extent of hyoid elevation were taken and the pharyngeal constriction ratio (PCR) determined after training. The change of the PCR and the relationship between hyoid elevation and the PCR were evaluated. The post-training PCR was significantly decreased compared to pre-training PCR (P < 0·05). There was a high inverse correlation between the hyoid elevation and the PCR (r = -1·992, P < 0·05). Effortful swallow with resistive electrical stimulation training increases pharyngeal constriction. It can be used as a treatment to improve pharyngeal constriction in patients with dysphagia.

Effects of neuromuscular electrical stimulation combined with effortful swallowing on post-stroke oropharyngeal dysphagia: a randomised controlled trial.

Neuromuscular electrical stimulation (NMES) has been used as a therapeutic intervention for dysphagia. However, the therapeutic effects of NMES lack supporting evidence. In recent years, NMES combined with traditional swallowing therapy has been used to improve functional recovery in patients with post-stroke dysphagia. This study aimed to investigate the effects of effortful swallowing combined with neuromuscular electrical stimulation on hyoid bone movement and swallowing function in stroke patients. Fifty stroke patients with mild dysphagia who were able to swallow against the resistance applied by using NMES and cooperate actively in training were included. This study was designed as a 6-week single-blind, randomised, controlled study. In the experimental group, two pairs of electrodes were placed horizontally in the infrahyoid region to depress the hyoid bone. The NMES intensity was increased gradually until the participants felt a grabbing sensation in their neck and performed an effortful swallow during the stimulation. In the placebo group, the same procedure was followed except for the intensity, which was increased gradually until the participants felt an electrical sensation. All participants underwent this intervention for 30 min per session, 5 sessions per week, for 6 weeks. Videofluoroscopic swallowing studies (VFSS) were carried out before and after the intervention and kinematics of the hyoid bone and swallowing function were analysed based on the VFSS. The experimental group revealed a significant increase in anterior and superior hyoid bone movement and the pharyngeal phase of the swallowing function. This intervention can be used as a novel remedial approach in dysphagic stroke patients.

Diaphragmatic breathing for rumination syndrome: efficacy and mechanisms of action.

BACKGROUND: While high resolution esophageal manometry combined with impedancometry has demonstrated that gastric pressurizations lead to rumination, the contribution of upper esophageal sphincter (UES) and esophagogastric junction (EGJ) function to rumination is unclear. Behavioral therapy with diaphragmatic breathing (DB) can reduce rumination. We aimed to evaluate the pressures in the stomach, EGJ and UES during rumination and the effects of DB augmented with biofeedback therapy. METHODS: Sixteen patients with rumination were studied with manometry and impedancometry before and after a meal. The postprandial assessment comprised three periods: before, during, and after DB augmented with biofeedback therapy. KEY RESULTS: All patients had postprandial rumination, which was associated (p < 0.001) with increased gastric pressure and reversal of the postprandial gastroesophageal pressure gradient from -4 (-43 to 18) before to 20 (7-79) mmHg during rumination. The EGJ pressure was lower (p < 0.001) during gastric pressurizations that were associated with rumination vs those that were not. The UES also relaxed, almost completely, during rumination. Patients had a median (range) of 5 (2-10) rumination episodes before, 1 (0-2) (p < 0.001) during, and 3 (1-5) after (p < 0.001 vs during) diaphragmatic breathing. During manometry and impedancometry, DB was well-tolerated and learned within 5 min. Diaphragmatic breathing increased EGJ pressure (p < 0.001) and restored a negative gastroesophageal pressure gradient (-20 mmHg [-80 to 7]). CONCLUSIONS & INFERENCES: Diaphragmatic breathing aided with high resolution esophageal manometry is well-tolerated, effective and averts the gastroesophageal pressure disturbance that leads to rumination.

The complexity of globus: a multidisciplinary perspective.

Globus is a topic of interest for many specialties including otorhinolaryngology, gastroenterology and psychiatry/psychosomatic medicine, but, although many hypotheses have been suggested, key questions about its aetiology remain. This Review provides an overview of the extensive literature concerning this topic and discusses the quality of the evidence to date. Globus has been associated with oropharyngeal structural lesions, upper oesophageal sphincter disorders, oesophageal disorders, GERD, psychosocial factors and psychiatric comorbidity. However, findings are often contradictory and the literature remains highly inconclusive. Indeed, with the exception of patients with structural-based globus, the Rome III criteria for functional globus only apply to a subgroup of patients with idiopathic globus. In clinical reality, there exists a group of patients who present with idiopathic (nonstructural) globus, but nevertheless have dysphagia, odynophagia or GERD-exclusion criteria for globus diagnosis according to Rome III. The symptomatology of patients with globus might be broader than previously thought. It is therefore crucial to approach globus not from one single perspective, but from a multifactorial point of view, with focus on the coexistence and/or interactions of different mechanisms in globus pathogenesis. This approach could be translated to clinical practice by adopting a multidisciplinary method to patients presenting with globus.

Effortful swallowing training combined with electrical stimulation in post-stroke dysphagia: a randomized controlled study.

We tested the effect of effortful swallow combined with surface electrical stimulation used as a form of resistance training in post-stroke patients with dysphagia. Twenty post-stroke dysphagic patients were randomly divided into two groups: those who underwent effortful swallow with infrahyoid motor electrical stimulation (experimental group, n = 10) and effortful swallow with infrahyoid sensory electrical stimulation (control group, n = 10). In the experimental group, electrical stimulation was applied to the skin above the infrahyoid muscle with the current was adjusted until muscle contraction occurred and the hyoid bone was depressed. In the control group, the stimulation intensity was applied just above the sensory threshold. The patients in both groups were then asked to swallow effortfully in order to elevate their hyolaryngeal complex when the stimulation began. A total of 12 sessions of 20 min of training for 4 weeks were performed. Blinded biomechanical measurements of the extent of hyolaryngeal excursion, the maximal width of the upper esophageal sphincter (UES) opening, and the penetration-aspiration scale before and after training were performed. In the experimental group, the maximal vertical displacement of the larynx was increased significantly after the intervention (p < 0.05). The maximal vertical displacement of the hyoid bone and the maximal width of the UES opening increased but the increase was not found to be significant (p = 0.066). There was no increase in the control group. Effortful swallow training combined with electrical stimulation increased the extent of laryngeal excursion. This intervention can be used as a new treatment method in post-stroke patients with dysphagia.

[Electric stimulation in dysphagia therapy--a review]. / Elektrische Stimulation in der Dysphagietherapie - Eine Ubersicht.

In the last years an increased interest in the electrical stimulation has consisted in the treatment of dysphagia. In the article we introduce the anatomical and physiological premises for the method. In a critical analysis the present state of art is represented, the clinical results are checked and the chances for the future are examined.