The intake behavior of humans and across mammalian species develops with bottle feeding along with mastication. Bottle feeding is a combination of sucking and swallowing in team with respiration. In the present investigation, based on the results of both videofluoroscopy and laryngofiberscopy performed on 3 patients, we investigated the mechanism of bottle feeding disorder. The results showed the cause of this disorder to possibly be the joint presence of the laryngeal closure function as an airway protective function and either laryngomalacia or a delayed swallowing reflex. In addition, if some impairment exists in the interlinkage between swallowing and respiration, then the link between sucking and swallowing may break down, thereby resulting in bottle feeding disorder. Based on the foregoing observations, the findings of both videofluoroscopy and laryngof iberscopy are thus considered to play a key role in elucidating the mechanism of the bottle feeding disorder.

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Dysphagia is a common problem in elderly persons and it is recently becoming an important social and medical issue in the field of health care. The age-related changes in the swallowing function were herein multilaterally assessed in 47 healthy aged volunteers (10 males and 37 females, 60-87 years old with an average of 68.9 years). The self-reported questionnaire showed 30% of the participants reported “aspiration during swallowing or drinking”, 23% of “aspiration before swallow”, and 13% of “increasing dysphagia recently”, thus indicating a potential subclinical swallowing disorder in an aged population. By videoendoscopic observations, the salivary pooling in the vallecula and piriform sinuses, glottal-closure reflex, and pharyngeal clearance after swallowing 3ml of blue-dye water was evaluated and graded according to a scale of 0 to 3. The percentages of disturbed swallowing function, with a score of 2 or 3, were 19%, 13% and 25%, respectively. Videofluorography showed significant prolongations of the pharyngeal transition time and a laryngeal elevation delay time with aging, despite of insignificant changes in the distances of hyoid and laryngeal elevation. These disorders had an increased prevalence in older (≥70 years) persons. In conclusion, the present study revealed an increasing risk of swallowing disorder associated with normal aging.

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with a flexible laryngoscope and a probe. [Materials and methods] An endoscopic sensory test with probes was conducted in nine healthy young adults who were less than 50 years of age and nine elderly adults who were all over than 70 years of age. We developed a flexible laryngoscope with an internal port and probes with nylon monofilaments of four different diameters (0.06, 0.13, 0.20, 0.30 mm) for this study. After anesthetizing the nose with 2% lidocaine jelly, a flexible laryngoscope was then passed via the nose, while the distal tip was placed in the oropharynx. Each probe was inserted into the internal port and then the nylon monofilament attached to the probe was touched to the mucosa of the epiglottis and arytenoids. The result was judged based on both the subjective symptoms and the objective signs demonstrated by the laryngeal adductor reflex. The sense threshold was determined after inspecting the size of the nylon monofilament. [Results] Neither the young nor elderly adults showed any difference in the sense threshold according to the site of the inspection. The sense threshold was significantly high in the epiglottis in the elderly adults in comparison to the young adults (p<0.05). The subjective symptoms and objective signs were also closely corresponded to each other. In addition, no adverse events were observed. [Conclusion] We have developed and tested a relatively safe and effective sensory discrimination test consisting of a flexible laryngoscope and a probe.

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We recently established a support team for patients with dysphagia, in April 2005 and we herein report the progress of this system and discuss some of the problems that have so far been identified. The need for such a team has been widely recognized, and the number of cases that are being referred to our team has therefore increased. However, the cooperation among the various team members is still somewhat unsatisfactory. In addition, there is still an insufficient number of qualified specialists belonging to this support team. It is expected that the number of patients referred to our support team will increase dramatically in the future and, as a result, it is essential to improve the performance and cooperation among all members of this support team.

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Purpose: The activation patterns of the cerebral cortex were analyzed by near-infrared spectroscopy (NIRS) on swallowing and swallow-related movements. Materials & Methods: Sixteen healthy males were evaluated by ETG-9000 (Hitachi). The block task of the oris, tongue, and the pharyngeal muscles were evaluated separately. A single task was performed for swallowing followed by an auditory cue (a command or a volitional swallow) or 1ml/sec distilled water infusion into the oral cavity by an infusion pump. Results: The activation area of the oris muscle, tongue protrusion and pharyngeal muscle were separated in the frontal lobe. The Oxy Hb increased more in the volitional swallow than in the natural swallow. Conclusion: We therefore conclude that the activation of the cerebral cortex is more closely associated with volitional swallow than with natural swallow. NIRS is a putative method for evaluating the activation of the cerebral cortex related to swallowing.

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We encountered a dysphagial patient, who had undergone a salvage partial laryngectomy after radiotherapy for early stage (T2) supraglottic cancer. We therefore performed a direct laryngoscopic laser supraglottic laryngectomy. Three months after the surgery, he began to have difficulty in swallowing. He presented with several important problems, including severe pulmonary emphysema, paroxysmal atrial fibrillation, postgastrectomy syndrome and normal aging. The management of chronic dysphagia requires a team approach with a swallowing team, a speech-language-hearing therapist, a nutritional support team and psychological counseling. After undergoing such coordinated therapies, the patient was able to regain his normal swallowing function.

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Patients with advanced tongue cancer generally undergo an extensive resection and reconstruction with a microvascular free flap. However, we have encountered patients who develop postoperative dysphagia due to an insufficient reconstructed tongue volume after surgery for advanced tongue cancer. A tissue expander was inserted into the tongue base under local anesthesia and then the optimal position and volume of the tissue expander was determined by fluoroscopy. Under general anesthesia one week later, a formed omentum was then inserted into the tongue base after replacing the tissue expander. The omentum has some advantages as a tissue filler, such as the fact that it is large fatty vascular rich tissue which can be easily formed into the ideal desired shape. Our minimally invasive method using omental tissue immediately improved two patients with postoperative dysphagia due to oral phase dysfunction.

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Our experience of 3 cases with dysphagia due to cranial nerve palsy as a late complication after radiation therapy for nasopharyngeal carcinoma (NPC) is herein reported. The cases consisted of two males and one female, ranging in age from 20 to 41 years old at the time of radiation therapy. Two cases received conventional radiation therapy alone while one case was given a combination of chemotherapy and radiotherapy. All patients began to suffer from dysphagia from eight to fifteen weeks after the therapy. All cases had bilateral hypoglossal nerve palsy with several sensory and motor disturbances of the pharynx and larynx. The method of intermittent oral-esophageal tube feeding was performed in one case, however, the other one case had to undergo a total laryngectomy in order to prevent aspiration pneumonia. Recently, the combination of chemotherapy and radiotherapy is frequently performed in order to improve prognosis of NPC. As a result, the occurrence of dysphagia associated with this therapeutic regimen and caused by a late disturbance of the cranial nerve may therefore increase in future.

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To evaluate type-I thyroplasty in order to achieve an improvement in the swallowing function of patients with unilateral vocal fold paralysis, 16 cases with aspiration symptoms were reviewed. All cases were treated by type-I thyroplasty alone under local anesthesia. The postoperative swallowing functions were examined by means of a fiberoptic evaluation, video fluoroscopy and clinical symptoms of dysphagia. In 14 of 16 cases, the dysphasia severity scale was observed to improve, while the maximum phonation time increased. As a result, type-I thyroplasty is therefore considered to contribute to an improvement of dysphasia caused by unilateral vocal fold paralysis.

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A modified surgical separation of the larynx from the trachea enables the preservation of phonetic function, while also preventing aspiration. Without a blind-end closure of the laryngeal side of the severed trachea, the end of the proximal portion of the trachea was held open as if to form a tracheal stoma. A double-cuffed tracheal tube was then inserted into this tracheal stoma. The upper cuff maintained an airtight closure of the trachea while the lower cuff served to stabilize the device. A breathing tube with a speech valve linked the trachea to this tube, thus allowing the expiratory air into the larynx for phonation. By means of this surgical procedure, it was therefore found to be possible to prevent aspiration while also preserving the speech function for patients to be able to maintain their phonetic function.

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We performed laryngotracheal separation on six pediatric neurological impaired patients and the effectiveness of laryngotracheal separation and the postoperative improvement of quality of life on both the patients and the caregivers were evaluated. Laryngotracheal separation dramatically decreased the frequency of suction. In addition, both aspiration pneumonia and respiratory disorders were well controlled after the operation. The burden on the caregiver was thereby reduced. There were also no significant complications accociated with the laryngotracheal separation. Laryngotracheal separation can therefore help to prevent neurologically impaired children from performing aspiration, thereby providing them with a higher QOL.

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We treated 9 patients with intractable aspiration, for whom no chance of recovery of the laryngeal function including phonation and protection of the air way was expected, from 1999 to 2005: including 5 with multiple and/or recurrent cerebrovascular disease, 3 with cerebral palsy and 1 with neuromuscular disease who was on a respirator. Although all had received preoperative nutritional support, 6 of 9 patients presented with hypoalbuminemia. Pharyngeal cultures revealed most of them to have pharyngeal colonization with methicillin-resistant Staphylococcus aureus, pseudomonas aeruginosa, or both. The series of surgical procedures included tracheoesophageal diversion procedures in 4 cases and a staple-assisted laryngectomy in 6 involving one case of salvage surgery after undergoing the tracheoesophageal diversion procedure. A postoperative tracheocutaneous fistula developed in 2 of 4 who received the former procedure, while no postoperative fistula formation was observed in the patients receiving the latter procedure. Finally, aspiration was successfully prevented in all patients. We should take the aforementioned two risk factors into consideration when performing surgery to separate, the upper digestive tract from the respiratory tract. A staple-assisted laryngectomy is thus considered to have certain advantages in the management of patients with intractable aspiration, because it provides a reliable watertight closure of the pharyngeal defect without inducing wound contamination due to pharyngeal secretions.

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