Dysphagia in Parkinson's disease: Pharyngeal manometry and fiberoptic endoscopic evaluation.

OBJECTIVE: Dysphagia is a common symptom in Parkinson's disease (PD) and it represents a negative prognostic factor because of its complications. This study is to evaluate pharyngeal dysphagia for boluses of various consistencies with Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and Pharyngeal High-Resolution Manometry (PHRM) in a group of PD patients, making a comparison between the information provided by the two exams. METHODS: Group of 20 patients affected by PD was selected and initially subjected to a qualitative evaluation of the swallowing performing FEES. Subsequently, they were evaluated by PHRM to identify quantitative measures associated with pressures expressed by pharyngeal organs during swallowing. Values obtained in the study group were compared with those recorded in a group of 20 healthy subjects. RESULTS: Study showed that Pmax (the maximum pressure elicited by the single pharyngeal muscle structures involved in swallowing) was significantly lower than the control group (p<0.05) for all the boluses and consistency tested, in particular for the Tongue base and the Cricopharyngeal muscle. Pmean pre-swallowing pressure (represents the mean value of a contraction in which basal and maximal pressure where normally calculated) was significantly higher compared to normal subjects for the Tongue base and the Cricopharyngeal muscle (p<0.05). Mean intra-swallowing pressure was higher for the Velopharynx and the Cricopharyngeal muscle, but lower for the tongue base. Pmax and Pmean at PHRM were altered independently to the degree of dysphagia detected at FEES, and they did not correlate either with the location of the residue or with the type of bolus. Images displayed at the FEES, found the corresponding biomechanical explanations in the PHRM, which also allowed us to quantify the extent of the dysfunction, through the calculation of the pressures generated in the various structures studied. CONCLUSION: PHRM is particularly useful in the early detection of dysphagia, when FEES may still show no evidence of abnormal swallowing.

Complications during Fiberoptic Endoscopic Evaluation of Swallowing in 5,680 Examinations.

OBJECTIVE: To evaluate retrospectively the incidence of complications during fiberoptic endoscopic evaluation of swallowing (FEES) in 5,680 examinations. PATIENTS AND METHODS: 5,680 patients were evaluated at the Department of Otorhinolaryngology, Audiology and Phoniatrics of Pisa University Hospital between January 2014 and December 2018, involving both inpatients and outpatients. Most common comorbidities included neurological pathologies such as stroke (11.8%), neurodegenerative diseases (28.9%) and a history of previous head and neck surgery (24.6%). The evaluation was conducted by clinicians with experience in swallowing for a minimum of 10 years with the assistance of one or more speech-language pathologists. RESULTS: In all patients studied the endoscope insertion was tolerated, and it was possible to visualize the pharyngolaryngeal structures. Three subjects refused to undergo the procedure after being informed regarding the protocol and were therefore not included in this study. Most patients reported discomfort (70.1%) and gagging (20.8%). In a minority of patients complications were recorded, such as anterior epistaxis (0.1%), posterior epistaxis (0.02%), vasovagal crises (0.08%) and laryngospasm (0.04%). Especially laryngospasm was recorded in patients affected by amyotrophic lateral sclerosis. Multivariate binary logistic regression showed that discomfort (OR 9.944; CI 7.643-12.937), chronic gastrointestinal diseases (OR 2.003; CI 1.518-2.644), neurodegenerative diseases (OR 1.550; CI 1.302-1.846) and brain tumors (OR 1.577; CI 1.179-2.111) were risk factors associated with minor complications. CONCLUSIONS: FEES proved to be easy to perform, well tolerated by the patients and cost-effective. It can be performed at the patient's bedside, and it is characterized by a low rate of complications. As a matter of fact, normally only discomfort, gagging and/or vomiting are reported. Complications occurred only rarely, such as anterior or posterior epistaxis episodes or vasovagal crises, but these are still easily managed. Exceptionally, more severe complications are reported: adverse drug reactions to substances such as blue dye (methylene blue) and local anesthetics (not used in our protocol), and laryngospasm.

Psychopathological aspects of dysphagia: a systematic review on correlations with eating disorders and other psychiatric conditions.

BACKGROUND: The effect of psychopathology on swallowing ability tends to be an overlooked issue in the assessment of dysphagic patients, possibly overshadowed by the given prominence to organic pathologies and the difficulties on the management of these patients. In addition, it should also be kept in mind that a great number of psychotropic drugs can affect swallowing adding problematic clinical issues in this area. Despite this, assessment of dysphagia should be considered as an extremely important issue, due to its impact on basic symptomatology, course of illness and quality of life. OBJECTIVE: This review aims to be an overview of relevant data on psychopathology associated with dysphagia and impairment of swallowing function. MATERIALS AND METHODS: An extensive bibliographic search was carried out in different medical databases (PubMed and Psycharticles) to comprehensively identify the most relevant publications available on dysphagia in eating disorders published until December 2020, according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) method. Research articles, either theoretical or empirical-based, published in peer-reviewed journals and in English language, were included. Case reports were also considered in the analysis when it was appropriate for completeness purposes. Titles and abstracts were reviewed according to the eligibility criteria. RESULTS: In total, 260 published studies were identified and 40 were finally selected after removal of duplicates and relevance. Primarily we investigated the correlation between dysphagia and eating disorders, analysing the complex relationship between the two conditions. Then we provided an overview of the assessment of dysphagic symptoms in other psychiatric syndromes. LIMITS: No exclusion criteria or statistical methods were applied nor was an assessment of study-level or outcome-level bias applicable for our purpose. The topic is vast and research bias could not be excluded; moreover, data available are heterogeneous and lacking systematic approach. CONCLUSIONS: With this review, the authors want to provide an overview of the most considerable and clinically useful information about the topic, focusing on some key points to disentangle psychiatric components from the complexity of patient with dysphagia. It should be a relevant concern for all clinicians and should be always thoroughly assessed, considered its frequency in clinical practice and its implications in every kind of patients' morbidity, mortality and quality of life. Special attention should be paid to mentally ill patients, who might display complex and multiple comorbidities, as well as consequences of abnormal eating behaviours, occasionally exacerbated by psychotropic medications. More systematic studies are needed, while it seems clear that a multidisciplinary approach is pivotal in the assessment and management of dysphagic patients. LEVEL OF EVIDENCE: Level I (evidence obtained from at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies).

Extensive Skull Base Osteomyelitis Secondary to Malignant Otitis Externa.

Skull base osteomyelitis is a severe complication of malignant otitis externa that affects the marrow of the temporal, sphenoid, and occipital bones. Skull base osteomyelitis is usually diagnosed based on clinical, microbiological, and radiological findings. Here, we present the imaging findings of a 76-year-old man who initially presented with right-sided malignant otitis externa, with the involvement of the otomastoid structures and ipsilateral temporal bone. Over the following 3 years, despite specific extended antibiotic therapy, the skull base osteomyelitis entirely involved the skull base, up to the contralateral petrous portion of the temporal bone, and it affected the cervical vertebral processes. This report describes an exceptional extent of unilateral malignant otitis externa with a severe involvement of the skull base on the contralateral side and the cervical spine.

A proposed multidisciplinary approach for identifying feeding abnormalities in children with cerebral palsy.

Children with neurodevelopmental disabilities, such as cerebral palsy, frequently have associated oral motor dysfunction, which leads to feeding difficulties, risk of aspiration, prolonged feeding times, and malnutrition with its attendant physical compromise. The authors propose a comprehensive multidisciplinary assessment, including neurological and dysphagia examination and ear, nose, and throat examination, to evaluate clinical indicators and severity of feeding impairment in children affected by neurodevelopmental disorders. A representative sample of 40 children with cerebral palsy (spastic, dyskinetic, or mixed), intellectual disability, and feeding problems was included in the study. A specific multidisciplinary evaluation and standardized mealtime observation in patients with cerebral palsy appear feasible and appropriate to recognize proactive indicators of dysphagia and to establish personalized programs of gastric and rehabilitative interventions.

Reasons for revision surgery after orbital decompression for Graves' orbitopathy.

OBJECTIVES: An analysis of complications and causes of failure in orbital decompression necessitating a second operation. METHODS: Between December 1992 and April 2007, 375 patients (719 orbits) were operated on using various techniques. Fourteen patients were initially operated on in our unit: 8 (group A1) were re-operated on after a short time due to complications connected with the decompression operation, 7 (group A2) were operated on after some time due to recurrence of the illness or unsatisfactory decompression (one patient is in both group A1 and A2). Five patients (group B) underwent a first operation elsewhere. RESULTS: For group A1 the most serious complications were connected to the nasal approach. For group A2 the operations were performed either because of a neuropathy recurrence or for further proptosis reduction due to recurrence or patient dissatisfaction. Lack of preoperative data hinders conclusions about group B, apart from one patient where the operation had not resolved a serious optic neuropathy after decompression based on Olivari technique combined with three-wall operation according to Mourits and colleagues (1990). CONCLUSIONS: We can deduce from group A1 that extreme attention is necessary during endonasal access, from group A2 that balancing the eyes is advisable, sacrificing maximum proptosis reduction to gain greater patient satisfaction, and from group B that decompression of the orbital apex is fundamental in the case of neuropathy.

Orbital decompression in graves' ophthalmopathy by medial and lateral wall removal.

OBJECTIVE: The objective of this study is to describe a technique for balanced orbital decompression and to analyze the results. METHODS AND MATERIALS: We conducted a retrospective study of 140 patients (276 orbits). Orbital decompression was carried out by removal of the medial orbital wall by ethmoidectomy and complete removal of the lateral wall by bringing out the entire sphenoid wing together with part of the zygomatic bone down to the inferior orbital fissure. RESULTS: One hundred thirty-six patients underwent bilateral decompression, 4 patients underwent monolateral decompression. Proptosis was reduced on average by 5.3 mm; 28 (20%) patients showed onset or worsening of diplopia. CONCLUSIONS: Medial and lateral approach allows a balanced orbital decompression. As some patients may present different degrees of proptosis and visual impairment, we stress the importance of carefully weighing the preoperative conditions of the individual patient when choosing the surgical approach.