The effect of intensified nonverbal facilitation of swallowing on dysphagia after severe acquired brain injury: A randomised controlled pilot study.

BACKGROUND: There is little high-level evidence for the effect of the nonverbal facilitation of swallowing on swallowing ability in the subacute stage of rehabilitation following severe acquired brain injury (ABI). OBJECTIVE: To pilot test a randomised controlled trial to determine the effect of an intensification of the nonverbal facilitation of swallowing on dysphagia. METHODS: Ten patients with severe ABI and dysphagia were randomised into two groups at a highly specialised neurorehabilitation clinic.The intervention group received an intensification of the nonverbal facilitation of swallowing and the control group received basic care of the face and mouth in addition to treatment as usual for two sessions of 20 minutes per day for three weeks.Outcomes were Functional Oral Intake Scale (FOIS), Penetration Aspiration Scale (PAS), and electrophysiological swallowing specific parameters (EMBI). RESULTS: The intensified intervention was feasible. PAS and FOIS scores improved in both groups, with no differences between groups. The swallowing specific parameters reflected clinically observed changes in swallowing. CONCLUSIONS: PAS and FOIS are feasible instruments to measure dysphagia. It is possible and valid to measure swallowing frequency and kinematics using electromyography and bioimpedance. The definitive study should have widened inclusion criteria and optimise intervention timing to maintain patient arousal.

[Osteoradionecrosis of the sternoclavicular joint]. / Osteoradionekrose des Sternoklavikulargelenks.

BACKGROUND/OBJECTIVE: Osteoradionecrosis is a rare, but feared, late complication after radiotherapy of the head and neck region. Its localization to the sternoclavicular joint has rarely been described so far. MATERIALS AND METHODS: Data are from a retrospective study that included all patients admitted to the authors' clinic with osteoradionecrosis of the sternoclavicular joint during the last 5 years. Therapy and outcome were evaluated and compared to the established literature. RESULTS: Over the past 5 years, 2 patients have been treated for pronounced osteoradionecrosis of the sternoclavicular joint. Both patients had received postoperative radiotherapy for tumors of the neck and chest, and presented with lesions involving the clavicle and the sternum. After eliminating the suspicion of recurrent cancer, both radiologic imaging and histopathologic evaluation confirmed an infection. Aggressive debridement with partial claviculectomy, partial sternectomy, and reconstruction using a pectoralis flap lead to the patients' recovery. CONCLUSION: Osteoradionecrosis does not only affect bone, but also the surrounding soft tissue. Due to the changes associated with previous radiotherapy, osteoradionecrosis should always be treated with radical debridement of the infected area, followed by flap reconstruction using unaffected tissue. The prognosis for the patient is then good.

[Effect of body position on coordination of breathing and swallowing]. / Einfluss der Körperposition auf die Atem-Schluck-Koordination.

BACKGROUND: To allow passage of food, the swallowing process closes off the larynx and interrupts respiratory flow. Both the timing of the interruption of respiratory flow and the body position can affect the results of the swallowing process. OBJECTIVE: The effect of body position on the swallowing process and the coordination of breathing and swallowing is investigated. MATERIALS AND METHOD: A combined EMG/bioimpedance measurement system and a piezoelectric sensor were used to investigate coordination of breathing and swallowing of a range of food consistencies in three different body positions (90°, 45° and 0°) in healthy subjects. RESULTS: Investigations were carried out on 21 healthy subjects (12 ♂, 9 ♀). 762 swallows were recorded. Changing body position was found to have a statistically significant effect on swallow-related parameters (maximum laryngeal elevation and speed of laryngeal elevation) and breathing pattern (pre- and post-swallow breathing phases). The laryngeal elevation as well as the speed of the laryngeal elevation is influenced significantly by the consistency to be swallowed. The breathing pattern changes from saliva to solid food of inspiration/swallow/inspiration to expiration/swallow/expiration. A change of body position influences the parameters specific for swallowing and the breathing patterns significantly. CONCLUSIONS: This study demonstrates that body position affects coordination of breathing and swallowing and swallow-related parameters in healthy subjects. Our results indicate that patients should be enabled to adopt a position in which they are sitting at an angle of at least 45°.

[Fainting during ingestion. Deglutition syncope ]. / Ohnmachtsanfälle bei der Nahrungsaufnahme. Schlucksynkope.

MEDICAL HISTORY: A 49-year-old woman was referred to the ENT department with a 1.5-year history of dysphagia accompanied by globus sensation and regurgitation as well as recurrent syncopal attacks associated with swallowing solid foods. CLINICAL FINDINGS: Endoscopic examination revealed hyperplasia of the tongue base and redness of the aryepiglottic region. An axial hiatal hernia (> 3 cm) was seen on esophago-gastro-duodenoscopy. Esophageal manometry showed a diffuse esophageal spasm. Holter monitoring (24 h) revealed a third-degree atrioventricular block. THERAPY: The patient's symptoms resolved following placement of a permanent cardiac pacemaker. Globus sensation and regurgitation persisted. Treatment with proton pump inhibitors was successful. The final functional endoscopic evaluation of swallowing revealed no relevant findings. CONCLUSION: We describe a case of a rare and extreme form of a vagal reflex. Deglutition syncope can be successfully treated by a multidisciplinary team consisting of otorhinolaryngologists, neurologists and cardiologists.

Dysphagia in acute tetraplegics: a retrospective study.

STUDY DESIGN: Retrospective study. OBJECTIVES: Swallowing disorder in patients with tetraplegia represents a problem. Incidence and clinical data were examined to determine the influencing factors. SETTING: Level I trauma Center, Berlin, Germany. METHOD: Retrospective study (1 September 1997-31 December 2002) on hospitalized patients with acute tetraplegia. The patients' swallowing ability was examined both clinically and endoscopically, and the results correlated with clinical data. RESULTS: A total of 175 patients (144 (82.29%) male patients and 31 (17.71%) female patients (4.6:1) were studied. The peak age groups (43.45, +/-18.98, 14-89 years) were 20-30 years and over 60 years. C4-C6 were most commonly affected. Tetraplegia was trauma-related in 147 (84%) patients. Twenty-eight (16.0%) patients appeared to be suffering from a swallowing disorder on first feeding, 23 (82.14%) patients with dysphagia were tracheotomized. The level of tetraplegia (chi (2)=19.8; P<0.05), tracheotomy (chi (2)=21.7; P<0.05) and the duration of ventilation (chi (2)=24.84, P<0.05) were all found to be statistically significant factors in the development of a swallowing disorder. Age, surgical approach, level of tetraplegia, severity of paralysis and the need for tracheotomy were predictive of dysphagia in 73.14% patients. Five patients with dysphagia died (because of causes other than dysphagia) and 10 patients were discharged with a feeding tube. CONCLUSION: No single trigger for a swallowing disorder in acute tetraplegia was found. A combination of multiple factors (level of tetraplegia, severity of paralysis, tracheotomy, accompanying injuries and accompanying illnesses) restricts swallowing and compensation of changes, to the extent that a swallowing disorder becomes apparent.

[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.

[Relative value of BAHA testing for the postoperative audiological outcome]. / Wertigkeit der BAHA-Testung für das postoperative Hörergebnis.

BACKGROUND: Bone-anchored hearing aids provide a therapy option for patients with conductive and mixed hearing loss, with the possibility of audiological rehabilitation. Test rod and tension headband offer the patient a preoperative impression of their postoperative hearing. The aim of this study was to evaluate the tools available for preoperative assessment of candidates for bone-anchored hearing aids and to ascertain predictive audiometric values. METHODS: Following implantation of a BAHA Compact system, sound and speech audiograms were performed in each of 16 patients with the bone-anchored BAHA device and with test rod and tension headband. RESULTS: Both with the BAHA and with the test devices, closure of the air-bone gap occurred and resulted in a clear improvement in hearing threshold and speech perception. The threshold increase with the BAHA was 9 dB greater on average (mean) than that measured with the test rod and the tension headband. Examinaation of speech perception indicated a mean advantage of 14-20% for the anchored BAHA system over the tension headband in monosyllabic testing. CONCLUSION: Preoperative testing before providing a BAHA system is a good way of predicting what level of hearing and speech perception can be expected after implantation.

[Posttreatment rehabilitation of swallowing in patients with head and neck cancer]. / Schluckrehabilitation nach moderner Tumortherapie im Kopf-Hals-Bereich.

Dysphagias after a tumor therapy in the head neck area are complications which can have serious consequences for the patients. An early interdisciplinary diagnostics and the induction of appropriate therapeutic measures are necessary to minimize the number and the results of these complications. In this review the conditions, possibilities and limits of the rehabilitation of dysphagia are discussed.

[Displacement of a stapes piston as a consequence of whiplash injury with head impact]. / Stapesprothesendislokation infolge HWS-Distorsion mit Kopfanprall.

We report the case of a 60 year old patient suffering from a displacement of her stapes piston after a rear-end collision with whiplash injury. Immediately after the accident she complained hearing loss and tinnitus. During the following days, the patient developed vertigo with lateropulsion. Diagnostic tympanoscopy showed a piston dislocation with migration into the vestibulum as a result of the blunt head trauma.

[Extra-abdominal desmoid tumors. Case report and literature review]. / Extraabdominelle Fibromatose. Fallbericht und Literaturübersicht.

Musculoaponeurotic fibromatosis or desmoid tumors are rare. We report the case of a 57 year old woman with a slowly growing tumor behind the sternocleidomastoid muscle, which was completely removed. Histological examination confirmed the clinical suspicion of a desmoid tumor. Desmoid tumors are aggressive, locally infiltrating, non-metastasizing tumors with a high local recurrence. Genetic, endocrine and physical factors have been implicated as causative agents. The diagnosis is made histologically, reactive fibromatosis and fibrosarcoma must be eliminated in differential diagnosis. By the combination of different radiographic techniques, it is possible to describe the tumors and differentiate between vessels, nerves and bones. The therapy of the choice is the surgical resection. Adjuvant therapy, such as x-ray treatment, chemo- and hormone therapy, are indicated when the tumor is inoperable or too extensive for surgery.

[Mode-of-action of manual medicine in the cervical spine]. / Wirkmechanismen manueller Medizin an der Halswirbelsäule.

Manual medicine aims at diagnosing and treating different disorders of the musculoskeletal system. It is a multidisciplinary approach with special emphasis on reversible disorders of the joints, muscles and ligaments. This treatment conception includes chirotherapy, physical therapy and drug treatment. The spine, an in particular the cervical spine, is treated primarily for joint disorders characterized by a variety of symptoms (e.g.headache, vertigo, dizziness, blurred vision). Manual medicine should be an integral part of modern clinical otolaryngology.

[Modified set back tongue flap: an alternative surgical approach in the reconstruction of defects of the base of the tongue]. / Der modifizierte Set-back-Zungenlappen. Eine Alternative in der Rekonstruktion von Zungengrunddefekten.

The base of the tongue after tumor resection can be reconstructed in several ways. In addition to direct suturing of small defects, a variety of local or microvascularly anastomosed flaps have been described. The present paper is aimed at introducing a local tongue flap for the reconstruction of medium-sized defects. Six patients were treated at the hospital between 1999 and 2002 with the above technique to cover defects affecting one-half to three-fourths of the base of the tongue. One patient had secondary bleeding and the other one experienced no complications. Nutrition could be started after 7.5 days (4-12) postoperatively on average. The tracheostomy was closed at 16.2 days (12-22) on average after the initial operation. The hospitalization of the patients was 20.3 days (15-27) on average. The modified set back tongue flap is an alternative in the reconstruction of subtotal defects of the base of the tongue. Easy handling, good functional outcome in swallowing, and the low complication rate were advantageous in the present series.

Wirkmechanismen manueller Medizin an der Halswirbelsäule.

Manual medicine aims at diagnosing and treating different disorders of the musculoskeletal system. It is a multidisciplinary approach with special emphasis on reversible disorders of the joints, muscles and ligaments. The treatment conception includes chirotherapy, physical therapy and drug treatment. The spine, and in particular the cervical spine, is treated primarily for joint disorders characterized by a variety of symptoms (e.g. headache, vertigo, dizziness, blurred vision). Manual medicine should be an integral part of modern clinical otolaryngology.