Dynamic disorders of swallowing are caused by lesions of the neuro-muscular system that participates in swallowing. Aspiration resulting from such disorders can be classified into four types. This classification is helpful for selecting surgical treatments for aspiration as well as for difficulty in swallowing.
Type I. In this type, aspiration occurs when the larynx is elevated and closed during swallowing. It results from incomplete laryngeal closure. Mediofixation of the paretic vocal fold, suture of the bilateral ventricular folds, and/or fixation of the larynx in a high position yields good laryngeal closure. Cricopharyngeal myotomy leads bolus easily into the esophagus.
Type II. Aspiration takes place when the larynx descends and opens at the end of the second stage of swallowing. This type of aspiration results from a weak propelling force and/or a strong resistance at the entrance of the esophagus. The weak propelling force is attributed to an incompetent velopharyngeal closure, disturbances of tongue movement and/or a weak pharyngeal peristalsis. Pharyngeal flap operation, infrahyoid myotomy and/or reinforcement of the pharyngeal wall is the choice of treatment. In order to reduce the resistance at the entrance of the esophagus, cricopharyngeal myotomy and a fixation of the larynx in an antero-superior position are effective.
Type III. Aspiration occurs in both phases of laryngeal rising and falling.
Type IV. This type is observed in those patients who are unable to execute the movements of the second stage of swallowing. The inability of the second stage movements seems to be caused by one of the following two: a severe paralysis of the swallowing muscles and strong inhibitory stimuli to the swallowing center of the medulla oblongata. The latter is observed in those patients who would have a very severe aspiration if their swallowing center allowed them to execute swallowing. In this type, the bolus is transported from the mouth to the pharynx by the gravity and weak tongue movements. The larynx closes in reflex but does not present such rising and falling as are executed in normal second stage. When the larynx opens, the bolus staying in the pharynx enters the airway.

View full abstract

The authors reported the results of fluoroscopic examination of the hypopharynx and esophagus in 163 cases during the past three years. A video-tape recording system was utilized to evaluate detailed pathological findings in the hypopharynx and cervical esophagus, and to judge whether the findings would be functional or organic. In the present paper, the purposes of fluoroscopic examination were to estimate extension of the lesion in 38 cases of laryngeal and hypopharyngeal cancer, to find causative diseases of 17 cases of recurrent nerve palsy, and to search pathological lesions in remaining 108 cases who complained of abnormal sensation of the throat and difficulty in swallowing and were not diagnosed laryngoscopically.
Pathological lesions in the hypopharynx and esophagus were found in 58 (54%) of these 108 cases, and some of them had two lesions in both regions.
The lesions were diagnosed as follows; cervical osteophyte including Forestier's disease in 16 cases, esophageal web including Plummer-Vinson's syndrome in 14, hypopharyngeal lateral pouch and diverticulum in 17, esophageal diverticulum including Zenker's diverticulum in 7, esophageal cancer in 6, cricopharyngeal achalasia in 4 and miscellaneous in 3. The recent concepts of cervical osteophyte, esophageal web and hypopharyngeal and esophageal diverticulum were briefly reviewed and discussed. Finally, the authors emphasized the importance of utilization of video-tape recording or cinematographical system for fluoroscopic examination of the hypopharynx and esophagus because a rapid passage of contrast medium is present during the second phase of swallowing.

View full abstract

A case of dysphagia with acute onset due to polyneuritis cranialis is reported.
The patient was a 29-year-old female who had complained of dysphagia and hoarseness for approximately two weeks following common cold.
Clinical symptoms of dysphagia, right soft palate paralysis, right vocal cord paralysis and right accessorius cranial nerve paralysis commenced in two weeks after upper respiratory infection possibly by virus. Clinical diagnosis was made of dysphagia with sudden onset due to polyneuritis cranialis on the basis of the following findings:
1) The onset of symptoms (C_2-3) was rather abrupt following upper respiratory infection.
2) The paralysis of right IX N. glossopharyngeus, X N. vagus and XI N. accessorius was present.
3) Initial clinical symptoms disappeared in 40 days under therapeutic regimen of Vitamin B₁, B₁₂, corticosteroid and antibiotic administration.
4) The paralysis of right VII N. facialis and XII N. hypoglossus occurred in 4 months after disappearance of initial symptoms.
5) The paralysis of VII N. facialis disappeared in 2 months under the same therapeutic regimen as applied for initial clinical symptoms. However, XII N. hypoglossus remains paralyzed.

View full abstract

The authors reported the results of respiratory and excretory functions of the trachea in a case, inn which end to end anastomosis after annular excision of the stenotic trachea was performed and a polyethylene tube was retained in the trachea for 17 months. The results of spirometry and blood gas analysis were all normal before and after the extubation. To examine the excretory function, 15ml of Dionosil was injected into the trachea and disappearance of the contrast medium was observed successfully. The contrast medium was excreted smoothly through the outside of the tube by ciliary action of the tracheal mucous epithelium. It is concluded that retaining of a tube in the trachea is not so harmful and rather useful for prevention of the recurrent stenosis. By this experience, a case of tracheal stenosis due to tuberculosis was treated successfully with the same technique. And its clinical data were reported together with in this paper.

View full abstract

A review was made on 63 cases (males: females=43:20) with various kinds of foreign bodies of the tracheobronchial tree treated mainly at the ENT Department of Hirosaki University and at the Central Hospital of Aomori Prefecture. The youngest among the 63 cases was 6 month-old baby boy and the eldest was 63 year-old male. Bronchoscopic removal of foreign bodies was carried out without general anesthesia on 21 cases who were seen before 1967, whereas since 1968, ventilation bronchoscopy under general anesthesia has been in use when necessary. Postbronchoscopic tracheostomy was necessitated in only 1 case.
The 63 foreign bodies were classified into two categories, i. e. non-radiopaque and radiopaque, and the ratio was 45:18. Among the non-radiopaque foreign bodies, there were peanuts (24 cases), beans, seeds, corns or other vegetables (9 cases), pieces of meat (3 cases), plastic pencil cap (4 cases), plastic bullet of toy gun (2 cases), a part of plastic toy (2 cases) and celluloid pipe (1 case). Sixteen among the 24 cases with peanuts were under 2 years of age (males: females=11:5). The radiopaque foreign bodies were: needles (2 cases), drawing pin (2 cases), nail, single false tooth, head of ball-point pen, staple, screw of compass and dental reamer (1 case each). Among those, 2 staples located in the lingular division and a pin located in the right upper anterior bronchus (B³_α) were removed under X-ray TV monitoring.

View full abstract

A 1 year and 7 month old boy was referred from a pediatrician with cough and fever for one week. Although chest X-ray indicated no significant findings, feeble breath sounds were noted over the right chest on auscultation. A close fluoroscopic observation revealed an abnormal movement of the mediastinal shadow concomitantly with respiratory movements, which seemed indicative of the presence of a foreign body in the airway. Subsequent ventilation bronchoscopy disclosed a piece of peanut in the right main bronchus and a successful removal was performed.
A 16mm film made from a fluoroscopic videotape of the present case was analyzed and the abnormal movement of the mediastinal shadow was investigated as an evidence of the check valve action of the foreign body in the airway.

View full abstract

An 18 year-old male was admitted to the authors' hospital for the treatment of a difficulty in decannulation for 16 years after tracheostomy, which had been made for a subglottic stenosis due to congenital malformation of the laryngeal cartilage.
The stenosis was removed by laryngofissure, and a “trough” was made in the operated area by using a silicone T-tube as a stent. Seven months postoperatively, transplantation of a composite graft of the nasal septum was made to cover the anterior defect of the subglottic airway. Reconstriction of the airway has not been observed for seven months after the second operation.

View full abstract

An experimental animal model with inflammation of the respiratory tract was prepared using specific-pathogen-free (SPF) rabbits and exposing them to both O₃ and bacteria (Bordetella bronchiseptica).
In this experiment, the relation between the progress of inflammation and the changes in fibrinolytic activities in the local tissues and in the blood was studied.
The results obstained were as follows:
1. Microscopic observations of the respiratory tract showed that the strongest inflammatory change occurred 7 days after the exposure of the animals to the O₃ and bacteria for 3 days. Recovery was observed after 28 days.
2. The plasma fibrinogen level clearly increased along with the histological changes in the trachea and nasal septum, reached the maximum level on the 7th day and decreased to the normal level thereafter. The local fibrinolytic activity also changed along with the fibrinogen level.
3. The fibrinolytic activity in the euglobulin fractions was observed to reach its maximum on the 14th day.
4. The injection of t-AMCHA showed an inhibitory effect against both local and blood fibrinolysis, while the occurrence of respiratory inflammation and an increase in fibrinogen were not affected for the first 7 days. The administration of t-AMCHA was considered to promote healing of the experimental inflammation. The fibrinolysis in this model is considered to be one of the exacerbating factors for respiratory inflammation.

View full abstract

A 53 year-old female who had undergone subtotal thyroidectomy for Basedow's disease developed dyspnea postoperatively and tracheotomy was performed. The cause of dyspnea was found to be laryngeal stenosis due to left recurrent nerve paralysis associated with postoperative vocal cord edema. Dyspnea persisted even after the subsidence of edema and decannulation was unsuccessful. A surgical widening of the glottis was not attempted for avoiding possible postoperative dysphonia and misdegultition, but a permanent tracheal fistula technique was applied for decannulation. The tracheal mucosa was sutured to the skin around the tracheostoma after revising the stoma. Decannulation was successful and the postoperative course has been uneventful for 1 year except for occasional misdegultition.

View full abstract