Effects of Presbyphagia on Oropharyngeal Swallowing Observed during Modified Barium Swallow Studies.

OBJECTIVES: Understanding how aging impacts swallowing can help differentiate typical from atypical behaviors. This study aimed to quantify age-related swallowing alterations observed during a modified barium swallow study. DESIGN: Cross-sectional study. SETTING: Adult fluoroscopy suite in a metropolitan hospital at an academic center. PARTICIPANTS: 195 healthy adults distributed across 3 age categories: 21-39; 40-59; 60+ years. MEASUREMENTS: 17 physiologic components of swallowing across three functional domains (oral, pharyngeal, esophageal), including summed composite scores (Oral Total [OT] and Pharyngeal Total [PT]), from the validated and standardized Modified Barium Swallow Impairment Profile. RESULTS: Most components (65%) demonstrated no impairment (scores of "0"). The odds of a worse (higher) score increased significantly with age for: Tongue Control during Bolus Hold, Hyolaryngeal Movement, Laryngeal Closure, Pharyngeal Contraction, and Pharyngoesophageal Segment Opening. OT and PT scores for 40-59-year-olds were worse than the youngest group (p=.01 and p <.001, respectively). Adults 60+ years had significantly worse PT scores among all groups (p-values <.01). CONCLUSION: Oropharyngeal swallowing physiology evolves as healthy adults age and should be considered during clinical decision-making.

Self-reported Dysphagia and Pharyngeal Volume Following Whiplash Injury.

Difficulty swallowing has been reported following whiplash injury; however, the reasons remain poorly understood. A possible factor may be the observed changes in pharyngeal volume. The current exploratory study was designed to examine the prevalence of self-reported dysphagia after whiplash and the relationship with recovery status and change in pharyngeal volume. Data were available from a longitudinal study of adults with whiplash. Data included magnetic resonance imaging (MRI) of the cervical spine, the Dysphagia Handicap Index (DHI), and Neck Disability Index (NDI) collected over four timepoints (< 1 week, 2 weeks, 3 months, and 12 months post-injury). Initial cross-sectional analysis examined 60 patients with DHI data from at least one timepoint. A second, longitudinal analysis was conducted on 31 participants with MRI, NDI, and DHI data at both early (< 1-2 weeks) and late (3-12 months) timepoints. The pharynx was contoured on axial T2-weighted MRI slices using OsiriX image processing software and pharyngeal volume (mm3) was quantified. In the 60-patient cohort, prevalence of self-reported dysphagia (DHI ≥ 3) was observed in 50% of participants at least once in 12 months (M = 4.9, SD 8.16, range 0-40). In the longitudinal cohort (n = 31), mean total DHI significantly (p = 0.006) increased between early and late stages. There was no relationship (p = 1.0) between dysphagia and recovery status, per the NDI% score. Pharyngeal volume remained stable and there was no relationship between dysphagia and pharyngeal volume change (p = 1.0). This exploratory study supports the need for further work to understand the nature of dysphagia, extent of functional compromise, and the underlying pathophysiology post-whiplash.

Whiplash-Associated Dysphagia: Considerations of Potential Incidence and Mechanisms.

Non-specific self-reports of dysphagia have been described in people with whiplash-associated disorders (WAD) following motor vehicle collision (MVC); however, incidence and mechanistic drivers remain poorly understood. Alterations in oropharyngeal dimensions on magnetic resonance imaging (MRI), along with heightened levels of stress, pain, and changes in stress-dependent microRNA expression (e.g., miR-320a) have been also associated with WAD, suggesting multi-factorial issues may underpin any potential swallowing changes. In this exploratory paper, we examine key biopsychosocial parameters in three patients with persistent WAD reporting swallowing change and three nominating full recovery after whiplash with no reported swallowing change. Parameters included (1) oropharyngeal volume with 3D MRI, (2) peritraumatic miR-320a expression, and (3) psychological distress. These factors were explored to highlight the complexity of patient presentation and propose future considerations in relation to a potential deglutition disorder following WAD. The three participants reporting changes in swallowing all had smaller oropharyngeal volumes at < 1 week and at 3 months post injury and lower levels of peritraumatic miR-320a. At 3 months post MVC, oropharyngeal volumes between groups indicated a large effect size (Hedge's g = 0.96). Higher levels of distress were reported at both time points for those with persistent symptomatology, including self-reported dysphagia, however, this was not featured in those nominating recovery. This paper considers current evidence for dysphagia as a potentially under-recognized feature of WAD and highlights the need for future, larger-scaled, multidimensional investigation into the incidence and mechanisms of whiplash-associated dysphagia.

The pharyngeal contractile integral is a useful indicator of pharyngeal swallowing impairment.

BACKGROUND: A limitation to the expanded use of high-resolution pharyngeal manometry (HRPM) in clinical practice is the lack of useful pharyngeal parameters that are easy to interpret, generalizable between patients, and do not require specialized software. In this study, we sought to test the relationship between the pharyngeal contractile integral (PhCI) with videofluoroscopic abnormalities as assessed with the Modified Barium Swallow Impairment Profile© ™. METHODS: Adult dysphagic patients were recruited to undergo simultaneous HRPM and videofluoroscopy during a standardized swallowing protocol. KEY RESULTS: Thirty-six patients were included in the study. The mean PhCI was 247 mm Hg·cm·s (range 2-488 mm Hg·cm·s). The lower pharyngeal total (PT) group (N=20; mean PT=3.9) had a mean PhCI of 299 mm Hg·cm·s, while the higher PT group (N=16; mean PT=12.7) had a mean PhCI score of 188 mm Hg·cm·s (P=.01). There was also a significant negative correlation between normalized PhCI to PT scores (r=-.47; P=.004). Patients with higher PhCIs exhibited less severe penetration-aspiration scores on thin liquids (1.44 vs 3.78; P=.03) and all consistencies combined (1.21 vs 1.99; P=.03). CONCLUSIONS & INFERENCES: The PhCI is a useful indicator of the presence of pharyngeal swallowing impairment and is technically simple to calculate with currently available software programs. Advancement of software is necessary to refine the clinical value of this parameter. High-resolution pharyngeal manometry has the potential to be a valuable adjunct procedure for the evaluation and treatment of dysphagic individuals.

Respiratory-swallowing coordination in normal subjects: Lung volume at swallowing initiation.

This study was designed to investigate the significance of bolus types and volumes, delivery methods and swallowing instructions on lung volume at swallowing initiation in normal subjects in a single experiment using a multifactorial approach. Our broad range goal was to determine optimal lung volume range associated with swallowing initiation to provide training targets for dysphagic patients with disordered respiratory-swallow coordination. Our hypothesis was that swallows would be initiated within a limited range of quiet breathing lung volumes regardless of bolus volume, consistency or task. Results confirmed this hypothesis and revealed that swallows were initiated at mean lung volume=244ml. Cued swallows were initiated at lower quiet breathing volumes than un-cued swallows (cued=201ml; un-cued=367ml). Water boluses were initiated at slightly higher quiet breathing volumes than solids. Data suggest that swallows occur within a restricted range of lung volumes with variation due to instructions, bolus type and other experimental variables.

Optimal patterns of care in patients with chronic obstructive pulmonary disease.

An intimate relationship exists between the physiological processes of respiration and swallowing at all levels of neuromotor control and peripheral function in healthy adults. Little is known regarding the potential alterations in these patterns in patients with chronic obstructive pulmonary disease (COPD), yet the impact of swallowing impairment and aspiration on the health outcomes of patients with COPD may be significant. COPD is a common comorbidity in patients with head and neck cancer and neurological disorders seen by swallowing clinicians, and warrants consideration during swallowing treatment. This article summarizes reports of alterations in the nutritional status, airway protective mechanisms, and swallowing efficiency that potentially contribute to or exacerbate the chronic and debilitating pulmonary condition. Care guidelines are given for modification of eating and swallowing behavior to optimize the health status of the patient with COPD. The need for controlled clinical trials for validation of the impact of these care guidelines on clinical outcomes is explained.

Clinical utility of the modified barium swallow.

The purpose of this investigation was to evaluate the immediate and clinically relevant information gained from the modified barium swallow study and to determine the impact of the procedure on patient management. A database containing a nonrandom sample of 608 swallowing studies was reviewed. Results showed that only 10.4% of the studies were classified as normal examinations and aspiration occurred in 32.4%. However, swallowing abnormality without aspiration was recorded in 57.2% of the studies. Five additional outcome variables were assessed: referrals made to other specialties, effectiveness of applied compensatory strategies, treatment recommendations, mode of intake change, and diet grade change. Nearly 83% of the 608 studies showed change in at least one of the variables: needed referral to a specialist was identified on 26.3%; compensatory strategies that improved swallow physiology were identified on 48.4%; swallowing therapy was recommended on 37.2%; changes in mode of intake occurred on 31.4%; and diet texture changes were recommended on 43.8%. The low percentage of normal studies coupled with the high percentage of change in measurable variables indicate high clinical utility for the modified barium swallow study. The misguided tendency to refer to the modified barium study only as a tool for identifying aspiration and the appropriate utilization of the examination for identification of underlying abnormality in swallowing physiology are explained.