2011 Volume 15 Issue 1 Pages 64-69
The patient was an 86-year-old woman with a medical diagnosis of multiple cerebral infarction. The results of the initial evaluation were: repetitive saliva swallowing test, 0 time/30 s; modified water swallowing test, 1 point; and food test, 1 point, with all of them indicating the severest degree. A videofluoroscopic examination of swallowing (VF) showed severe cricopharyngeal dysfunction and reduced laryngeal elevation, and all of the jelly remained in the bilateral pyriform sinuses. The evaluation of quality of life (QOL) on a 5-grade scale of degree of satisfaction was 5, “dissatisfied,” the lowest grade. Indirect therapy in the form of a training plan was performed initially, but no change was observed, and so gastrostomy was performed. We then tried to perform swallowing training with a feeding tube according to Saigusa et al., but because swallowing by active movement of the tube was completely impossible, we devised a modified version of their method. In our method, we pass a thread via an external naris through the esophagus to the gastrostomy tube with an endoscope, and after connecting the thread at the external naris end to a urethral catheter, pull the thread at the gastrostomy tube end toward us, thereby enabling the patient to swallow by active-assistive movement of the urethral catheter. Although the swallowing movements were mainly due to active-assistive movements in the beginning, as a result of performing training for 8 weeks, swallowing movements by active movement eventually became possible, and VF revealed a marked improvement in the cricopharyngeal dysfunction. Training ended when the patient was transferred to another hospital, and although it never became possible for the patient to obtain her total nutritional requirements orally, a clear improvement in function was observed, and there was a dramatic improvement to a score of 1 “satisfied” in the evaluation of degree of satisfaction, an indicator of QOL. The above findings suggest the usefulness of a method that enables swallowing by active-assistive movement of a tube, when swallowing by means of active movement of the tube is difficult in patients with cricopharyngeal dysfunction complicated by pharyngeal dysphagia. Unlike rehabilitation of the limbs and trunk, it is anatomically difficult to act directly on the affected site, and so there have been very few attempts at rehabilitation of disorders in the pharyngeal stage of deglutition, particularly by passive movement or activeassistive movements. Accordingly, this useful method paves the way for the rehabilitation of pharyngeal dysphagia patients.
