Cutoff value of the geniohyoid muscle mass to identify sarcopenic dysphagia by ultrasonography.

PURPOSE: Determining the strength and area of the swallowing muscles is important in patients with sarcopenic dysphagia. Although the normative data on the strength of the swallowing muscles have been reported, those of the area of the geniohyoid muscle are poorly investigated. We investigated the cross-sectional area of the geniohyoid muscle in Japanese subjects without dysphagia using ultrasonography to determine the normative and cut-off values. METHODS: 142 subjects without dysphagia were included. The older group (age ≥ 65 years) included 36 (women 27/men 9) subjects, and the younger group (age ≤ 39 years) included 106 (women 54/men 52) subjects. The cross-sectional area of the geniohyoid muscle was measured by ultrasound. The mean of the younger group-2 standard deviation (SD) was calculated and used as a cut-off value for low swallowing muscle mass. RESULTS: The mean (SD) of the area of the geniohyoid muscle of each group was as follows: older women group 167.2 (32.6) mm2, older men group 193.2 (49.5) mm2, younger women group 247.3 (37.4) mm2, younger men group 313.1 (59.2) mm2. The mean 2SD of the geniohyoid muscle area in the younger women group was 172.5 mm2 and in the younger men group 194.7 mm2. CONCLUSION: We found that the cut-off value of the ultrasonographic cross-sectional area of the geniohyoid muscle was 172.5 mm2 for women and 194.7 mm2 for men. These values could be used as cut-off values for the mass of the geniohyoid muscle to identify patients with sarcopenic dysphagia.

Association of Existence of Sarcopenia and Poor Recovery of Swallowing Function in Post-Stroke Patients with Severe Deglutition Disorder: A Multicenter Cohort Study.

BACKGROUND: The effect of sarcopenia on the recovery of swallowing function, and the interaction among sarcopenia, nutrition care, and rehabilitation therapy are inconclusive. METHODS: This multicenter cohort study was conducted between November 2018 and October 2020 in convalescent rehabilitation hospitals in Japan and included post-stroke patients aged ≥65 years with dysphagia. All participants were assigned to sarcopenia and non-sarcopenia groups. The primary outcome was the achievement of ≥2 Food Intake Level Scale [FILS] gain, and the secondary outcomes included Functional Independence Measure (FIM) gain and efficiency. Considering the effect modification of energy intake and rehabilitation duration, logistic regression analyses were performed. RESULTS: Overall, 153 participants with (median age, 82 years; 57.5% women) and 40 without (median age 75 years; 35.0% women) sarcopenia were included. The non-sarcopenia group had more patients who achieved an FILS gain of ≥2 (75.0%) than the sarcopenia group (51.0%). Sarcopenia was independently associated with a poor FILS gain (odds ratio:0.34, 95% confidence intervals: 0.13-0.86) but not associated with FIM gain or efficiency. This association was not affected by the rehabilitation duration or energy intake. CONCLUSIONS: In conclusion, sarcopenia was negatively associated with the recovery of swallowing function in stroke patients without interaction by energy intake and rehabilitation duration.

Diagnosis and Treatment of Sarcopenic Dysphagia: A Scoping Review.

BACKGROUND: Sarcopenic dysphagia is a swallowing disorder due to sarcopenia involving the whole-body skeletal muscles and swallowing muscles. This scoping review aimed to explore the currently known information on the diagnosis and treatment of sarcopenic dysphagia and to clarify the types of research required to develop the field. METHODS: We searched the PubMed, MEDLINE, CINAHL, and Cochrane databases from their inception to October 2020, using the search terms "(sarcopenia or sarcopenic or myopenia or dynapenia) and (dysphagia or swallowing or deglutition) and (diagnosis or treatment)". Articles reporting diagnosis method and treatment of sarcopenic dysphagia were included. RESULTS: Twenty-one and eight articles reported on the diagnostic and treatment method, respectively. A diagnostic algorithm for sarcopenic dysphagia was most frequently used (n = 10). Other diagnostic methods included consensus diagnostic criteria for sarcopenic dysphagia (n = 4), sarcopenia and dysphagia without other causes of dysphagia (n = 4), and both sarcopenia and dysphagia (n = 3). The medical treatments for patients with sarcopenic dysphagia were described in single-patient case reports (n = 8) only. There were six articles reporting on a combination of rehabilitation and nutritional support. These reports showed the importance of interdisciplinary rehabilitation nutrition for improving patients' nutritional status and sarcopenia. CONCLUSIONS: A reliable and validated diagnostic algorithm was the most widely used diagnostic method for sarcopenic dysphagia. Only case reports have been published for the medical treatment of patients with sarcopenic dysphagia. Interdisciplinary rehabilitation nutrition may be useful for treating patients with sarcopenic dysphagia.

Relationship Between Tongue Pressure and Pharyngeal Function Assessed Using High-Resolution Manometry in Older Dysphagia Patients with Sarcopenia: A Pilot Study.

Tongue pressure is often used to evaluate swallowing muscle strength in dysphagia patients with sarcopenia. However, the amount of tongue pressure that reflects pharyngeal swallowing function is unclear. The aims of this descriptive study were (1) to assess the association between tongue pressure and swallowing function using high-resolution manometry (HRM), (2) to evaluate whether manometric parameters were related to maximum tongue pressure (MTP) and other sarcopenia-related factors, and (3) to evaluate the manometric characteristics of pharyngeal swallowing in sarcopenic dysphagia. Sixteen patients with dysphagia (13 men; mean age 85.0 ± 6.6) who were diagnosed with sarcopenia and sixteen healthy subjects (10 men; mean age 33.6 ± 7.2) were included. Evaluation of HRM parameters including velopharyngeal contractile integral (VPCI), mesohypopharyngeal contractile integral (MHPCI), upper esophageal sphincter (UES) relaxation duration, and UES nadir pressure was performed. HRM parameters of patients were compared with MTP, sarcopenia factors, and manometric parameters of healthy subjects. The VPCI showed no statistically significant differences between patient and healthy groups. In the patient group, the MHPCI was significantly lower (126.1 ± 76.6 vs 193.2 ± 34.1 mmHg cm s; p = 0.003), UES nadir pressure was significantly higher (10.5 ± 27.5 vs - 11.2 ± 6.7 mmHg; p < 0.001), and UES relaxation duration (318.0 ± 152.4 vs 520.6 ± 60.0 ms; p = 0.007) was significantly shorter than those in the healthy group. HRM parameters were not significantly correlated with MTP and sarcopenia factors. Older dysphagia patients with sarcopenia had weaker pharyngeal contractility and UES dysfunction. Manometric evaluation of pharyngeal function may not be significantly associated with MTP and sarcopenia-related factors. Further study is needed to clinically apply tongue pressure for evaluating sarcopenic dysphagia.

Digastric muscle mass and intensity in older patients with sarcopenic dysphagia by ultrasonography.

AIM: The aim of this study was to investigate digastric muscle mass and intensity between no sarcopenic dysphagia and sarcopenic dysphagia. METHODS: Patients aged ≥65 years were enrolled. According to the diagnostic algorithm for sarcopenic dysphagia, the patients were divided into two groups, no sarcopenic dysphagia and sarcopenic dysphagia. Handgrip strength, gait speed, skeletal muscle mass, tongue pressure, Mini Nutritional Assessment-Short Form and Food Intake LEVEL Scale were investigated. Digastric muscle mass and intensity were examined by ultrasonography. Univariate and multivariate analyses were performed to analyze two groups. Multivariate logistic regression analysis was performed to determine independent factors for the presence of sarcopenic dysphagia. To estimate the accuracy of diagnosing sarcopenic dysphagia, a receiver operating characteristic curve analysis was performed for digastric muscle mass and intensity. RESULTS: Forty-five patients (mean ± SD, 84.3 ± 7.8 years, 22 men, 23 women) including 19 no sarcopenic dysphagia and 26 sarcopenic dysphagia were examined. In sarcopenic dysphagia, lower BMI, Food Intake LEVEL Scale, Mini Nutritional Assessment-Short Form and smaller muscle mass and greater muscle intensity were found compared with no sarcopenic dysphagia. In multivariate logistic regression analysis, digastric muscle mass and intensity were identified as independent factors for sarcopenic dysphagia. The cut-off value of muscle mass was 75.1 mm2 (area under curve: 0.731, sensitivity: 0.692, specificity: 0.737) and muscle intensity was 27.8 (area under curve: 0.823, sensitivity: 0.923, specificity: 0.632). CONCLUSIONS: Digastric muscle mass was smaller and muscle intensity was greater in sarcopenic dysphagia than no sarcopenic dysphagia. Ultrasonography of digastric muscle, as well as the tongue and geniohyoid muscle, is useful. Geriatr Gerontol Int 2021; 21: 14-19.

Society of swallowing and dysphagia of Japan: Position statement on dysphagia management during the COVID-19 outbreak.

On April 14, the Society of Swallowing and Dysphagia of Japan (SSDJ) proposed its position statement on dysphagia treatment considering the ongoing spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The main routes of transmission of SARS-CoV-2 are physical contact with infected persons and exposure to respiratory droplets. In cases of infection, the nasal cavity and nasopharynx have the highest viral load in the body. Swallowing occurs in the oral cavity and pharynx, which correspond to the sites of viral proliferation. In addition, the possibility of infection by aerosol transmission is also concerning. Dysphagia treatment includes a broad range of clinical assessments and examinations, dysphagia rehabilitation, oral care, nursing care, and surgical treatments. Any of these can lead to the production of droplets and aerosols, as well as contact with viral particles. In terms of proper infection control measures, all healthcare professionals involved in dysphagia treatment must be fully briefed and must appropriately implement all measures. In addition, most patients with dysphagia should be considered to be at a higher risk for severe illness from COVID-19 because they are elderly and have complications including heart diseases, diabetes, respiratory diseases, and cerebrovascular diseases. This statement establishes three regional categories according to the status of SARS-CoV-2 infection. Accordingly, the SSDJ proposes specific infection countermeasures that should be implemented considering 1) the current status of SARS-CoV-2 infection in the region, 2) the patient status of SARS-CoV-2 infection, and 3) whether the examinations or procedures conducted correspond to aerosol-generating procedures, depending on the status of dysphagia treatment. This statement is arranged into separate sections providing information and advice in consideration of the COVID-19 outbreak, including "terminology", "clinical swallowing assessment and examination", "swallowing therapy", "oral care", "surgical procedure for dysphagia", "tracheotomy care", and "nursing care". In areas where SARS-CoV-2 infection is widespread, sufficient personal protective equipment should be used when performing aerosol generation procedures. The current set of statements on dysphagia management in the COVID-19 outbreak is not an evidence-based clinical practice guideline, but a guide for all healthcare workers involved in the treatment of dysphagia during the COVID-19 epidemic to prevent SARS-CoV-2 infection.

Sarcopenia and dysphagia: Position paper by four professional organizations.

This report was written by the Japanese Society of Dysphagia Rehabilitation, the Japanese Association of Rehabilitation Nutrition, the Japanese Association on Sarcopenia and Frailty, and the Society of Swallowing and Dysphagia of Japan to consolidate the currently available evidence on the topics of sarcopenia and dysphagia. Histologically, the swallowing muscles are of different embryological origin from somatic muscles, and receive constant input stimulation from the respiratory center. Although the swallowing muscles are striated, their characteristics are different from those of skeletal muscles. The swallowing muscles are inevitably affected by malnutrition and disuse; accumulating evidence is available regarding the influence of malnutrition on the swallowing muscles. Sarcopenic dysphagia is defined as dysphagia caused by sarcopenia of the whole body and swallowing-related muscles. When sarcopenia does not exist in the entire body, the term "sarcopenic dysphagia" should not be used. Additionally, sarcopenia due to neuromuscular diseases should be excluded; however, aging and secondary sarcopenia after inactivity, malnutrition and disease (wasting disorder and cachexia) are included in sarcopenic dysphagia. The treatment of dysphagia due to sarcopenia requires both dysphagia rehabilitation, such as resistance training of the swallowing muscles and nutritional intervention. However, the fundamental issue of how dysphagia caused by sarcopenia of the swallowing muscles should be diagnosed remains unresolved. Furthermore, whether dysphagia can be caused by primary sarcopenia should be clarified. Additionally, more discussion is required on issues such as the relationship between dysphagia and secondary sarcopenia, as well as the diagnostic criteria and means for diagnosing dysphagia caused by sarcopenia. Geriatr Gerontol Int 2019; 19: 91-97.

Disruption of the Obligatory Swallowing Sequence in Patients with Wallenberg Syndrome.

Although the sequence of events involved in swallowing varies among healthy adults, healthy adults demonstrate some consistent patterns, including opening of the upper esophageal sphincter (UES) prior to maximum laryngeal elevation (LE). Previous animal studies suggested that swallowing is regulated by a neuronal network in the medulla, and lateral medullary infarction, or Wallenberg syndrome, frequently causes dysphagia. This retrospective, observational, multicenter study aimed to determine if the sequence of swallowing events was disturbed in patients with Wallenberg syndrome compared with previously published reference data for healthy adults. The study subjects included 35 patients with Wallenberg syndrome admitted to three hospitals in Japan from 1/4/2009 to 31/3/2017. Sixteen timing events, including maximum LE and UES opening, and the intervals between events were measured. If the sequence of events was the same as in healthy adults, the interval value was positive, and if the sequence of events was opposite to that in healthy adults, the value was negative. The median interval from UES opening to maximum LE was - 0.02 s (range - 0.80 to 0.89, 95% CI - 0.14 to 0.10). About half of the Wallenberg cases showed negative values indicating that the sequence was reversed. These results suggest that lateral medullary infarction impairs the sequence of swallowing events.

Prediction of dysphagia severity: an investigation of the dysphagia patterns in patients with lateral medullary infarction.

OBJECTIVE: In order to identify the factors that influence the swallowing function in patients who develop Wallenberg syndrome (WS) following lateral medullary infarction (LMI), we examined various patient characteristics, including the passage pattern abnormality (PPA) of a bolus through the upper esophageal sphincter (UES). METHODS: Fifty-four pure LMI patients with dysphagia participated in this study. PPA, defined as the failure of bolus passage through the UES corresponding to the intact side of the medulla, was identified during videofluorographic swallowing evaluations of each patient. On brain magnetic resonance imaging, the subjects' lesions were classified vertically into three levels and horizontally into seven levels in relation to the involvement of the ambiguous and/or solitary nuclei. Logistic regression analyses were performed for age, sex, PPA and the vertical and horizontal sites of the lesions. RESULTS: In terms of severity, 15 subjects were categorized as having mild dysphagia, 26 subjects were categorized as having moderate dysphagia and 13 were categorized as having severe dysphagia. Subjects with cephalic lesions, greater vertical spread of the lesion and PPA were more likely to have severe dysphagia. PPA and a greater vertical spread of the lesion were related to the severity of the functional outcome (p<0.01). The horizontal extent of the lesion was not strongly related to the prognosis. CONCLUSION: The presence of PPA in LMI patients is suggestive of abnormalities in the swallowing pattern and, in turn, damage to the medullary central pattern generator. The presence of PPA and a greater vertical spread of the lesion can be useful predictors of severe dysphagia.

[Dysphagia with lateral medullary infarction (Wallenberg's syndrome)].

Dysphagia after lateral medullary infarction (LMI) is common. The dysphagia of LMI is dynamically characterized by a failure in triggering of the pharyngeal-phase swallowing movements, reduced output, and lack of coordination (swallowing pattern abnormality). Based on accurate evaluation, we can select suitable rehabilitative approaches for individual patients, including respiratory therapy, food modification, postural changes, and oral care. We focused on the absence of upper esophageal sphincter (UES) opening of the unaffected side of the medullae. The movement pattern was defined as failure of bolus passage through the intact side of the UES, occurring at least once during the videofluorographic evaluation of each individual. Three abnormal patterns of UES opening were classified. The passage pattern abnormality shows the failure of the stereotyped motor sequence. For severe cases, it is necessary to consider long-term treatment, including botulinum toxin injection or surgery to prevent aspiration and adequate nutritional management.

Two Japanese CADASIL families exhibiting Notch3 mutation R75P not involving cysteine residue.

Most previously reported mutations in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) result in an odd number of cysteine residues within the epidermal growth factor (EGF)-like repeats in Notch3. We report here R75P mutation in two Japanese CADASIL families not directly involving cysteine residues located within the first EGF-like repeats. Probands in both families had repeated episodes of stroke, depression, dementia as well as T2 high-intensity lesions in the basal ganglia and periventricular white matter, but fewer white matter lesions in the temporal pole on MRI. These families provide new insights into the diagnosis and pathomechanisms of CADASIL.

[Case of baroreflex failure after bilateral revascularization of the cervical carotid artery].

We report a patient of baroreflex failure two years after bilateral cervical internal carotid artery (ICA) revascularization. A 76-year-old hypertensive man was admitted to our hospital after suffering multiple syncopal events for the past 2 years prior to admission. He received bilateral surgical and endovascular revascularization for stenotic lesions of the ICA orifices 4 years ago. Intervention consisted of carotid endarterectomy and carotid stenting for the right and left ICAs, respectively. Head T2-weighted magnetic resonance images demonstrated multiple high intensity signals in the basal ganglia bilaterally. To investigate his autonomic function, head-up tilt test, 24-hour ambulatory blood pressure measurements, and Valsalva's maneuver were performed. The patient demonstrated marked orthostatic hypotension without increment of heart rate, increased variability of blood pressure and abnormal hypertensive surges in a single 24 hour period, and abnormal response of heart rate during Valsalva's maneuver. These findings were indicative of impaired baroreflex-mediated vasomotor and heart rate control. Other examinations involving hematological analysis, cardiac function assessment, and scintigraphy for pheochromocytoma were within normal limits except for a marked increase in plasma norepinephrine during hypertensive surge. We therefore considered that he had baroreflex failure resulting from previous bilateral ICA orifice revascularization. The patient was given diazepam during hospitalization. After then, his blood pressure stabilized somewhat and syncopal attacks were controlled. Our case suggests that patients, who undergo bilateral ICA orifice revascularization and present with syncopal attacks, should be considered baroreflex failure even if the patient is post-operative several years. Long-term follow up should therefore be necessitated in patients who undergo bilateral carotid revascularization.

Tandem balloon protection during emergency carotid artery stenting of a stenotic ICA lesion with intraluminal thrombus.

PURPOSE: To report a technique for emergency CAS of a stenotic internal carotid artery (ICA) lesion with an intraluminal thrombus, which predisposes to distal thromboembolism and could aggravate pre-existing neurological symptoms. CASE REPORT: A 77-year-old man with fluctuating stroke underwent successful emergency CAS for an ICA stenosis with intraluminal thrombus using a tandem balloon protection technique featuring proximal balloon blockade and a PercuSurge GuardWire system for distal protection. CONCLUSION: This experience suggests that emergency CAS with tandem balloon protection is a potential treatment for a stenotic lesion with an intraluminal thrombus in patients with fluctuating stroke.

Small artery dementia in Japan: radiological differences between CADASIL, leukoaraiosis and Binswanger's disease.

CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) is a hereditary small artery disease which is phenotypically similar to Binswanger's disease (BD), a nonhereditary form of small artery disease. Recent studies have indicated that lesions in the temporopolar, medial frontopolar areas and external capsule are frequently seen in Caucasian patients with CADASIL. However, it remains unclear whether magnetic resonance (MR) imaging findings are helpful in diagnosing small artery disease outside countries with Caucasian populations, since CADASIL is rare despite the high prevalence of small artery disease in Japan. We examined 58 patients with small artery disease, all of whom were devoid of major vessel occlusion or severe stenosis. These patients included 7 patients from 3 families with CADASIL, 27 nondemented patients with extensive leukoaraiosis (LA) and 24 patients with BD. On T(2)-weighted MR images, hyperintensities in the temporopolar areas were observed in all 7 patients with CADASIL, whereas these lesions were observed in only 1 subject from each of the nondemented LA and BD groups. Hyperintensities in the medial frontopolar areas were seen in 4 of the 7 patients with CADASIL (57%) and in 14 of the 24 patients with BD (58%), and were more frequent than in the nondemented LA group (4 of the 27 patients; 15%). In contrast, hyperintensities in the external capsule were frequently observed in all groups. Therefore, temporopolar lesions can also serve as diagnostic markers for CADASIL in non-Caucasian patients.