[in Japanese]

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[in Japanese]

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This report describes a rare case of a patient with a left medullary infarction in whom the bolus passage side of the cricopharyngeal region changed from the affected to the bilateral sides. The patient was a 57-year-old male admitted for a left lateral medullary infarction associated with a dissecting aneurysm of the vertebral artery. A videofluoroscopic examination of swallowing (VF) performed on the 31 st day the hospital demonstrated that the bolus passed only though the affected left side of the cricopharyngeal region and did not pass though the healthy side. The bolus normally tends to be transferred from the oral cavity to the affected side of pharynx. Intermittent oro-esophageal tube feeding, balloon dilatation of the cricopharyngeal region and stepwise food ingestion therapy using jerry diets with the right rotation of the neck in the left lateral position were therefore initiated. VF on the 87 th hospital day detected bolus passage on the healthy right side of the cricopharyngeal region, thus showing an alteration in the passage on the bilateral sides.

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We devised an operation to reinforce a paralyzed pharyngeal wall with polypropylene mesh, which was made for the treatment of an abdominal wall hernia as a new type of surgical treatment. We evaluated 8 cases that underwent an operation of pharyngeal wall reinforcement for the treatment of dysphagia associated with unilateral pharyngeal paralysis from January, 2005 to December, 2006. The pharyngeal clearance improved in 6 cases, except for 2 cases who showed poor swallowing initiation. This surgical technique is considered to be useful for treating unilateral pharyngeal paralysis by raising the stiffness of not only the pyriform sinus but also the walls from the oropharynx to the hypopharynx, thereby effectively increasing the deglutition pressure of the undamaged side.

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A 32-year-old male was diagnosed to have acute disseminated encephalomyelitis (ADEM) after suffering a viral illness. He complained of ataxic weakness and difficulty in swallowing. Magnetic resonance imaging (MRI) revealed multiple areas of high intensity, mainly in the brain stem and middle cerebellar peduncle. He was admitted to the ICU because of respiratory failure. He received three courses of methylprednisolone by pulse dose intravenous administration. In parallel with the steroid therapy, dysphagia rehabilitation was performed daily. As a result, the patient's swallowing function gradually recovered. In this case, a videoen-doscopic evaluation (VE) for the clinical follow-up of swallowing, an appropriate treatment course and active swallowing rehabilitation, were together found to be useful for obtaining an early recovery.

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The most useful modality for treating neck metastasis is a neck dissection. A neck dissection was previously performed as a radical neck dissection. However, disabilities in shoulder movement and swallowing function often occur after this procedure. Recently, a functional neck dissection has therefore been performed in order to avoid such postoperative complications. The current study for dysphasia after a neck dissection investigates patients with primary unknown neck metastasis and neck recurrence after chemoradiation. Eleven cases of dysphasia occurred after a neck dissection between 2003 and 2006. These cases resected the lower cranial nerves (IX, X, XII), or paralysis of these nerves occurred despite their preservation after surgery. Patients with dysphasia underwent rehabilitation to regain their swallowing function. However, rehabilitation was unsuccessful and the patients were thus required to undergo further surgery. Conclusion: A neck dissection with resection of the lower cranial nerves (IX, X, XII) may sometimes result in dysphasia. Consequently, surgery to prevent dysphasia should be performed simultaneously so that timely postoperative therapy can be carried out.

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The influence of a neck dissection on the swallowing function was examined in 16 cases. The neck dissection did not affect laryngeal elevation. However, the operation injured the pharyngeal branch of the vagus nerve, thus resulting in pharyngeal palsy. Therefore, the clearance of the pharynx deteriorated. Based on these findings, the preservation of the pharyngeal branch of the vagus nerve is thus considered to be important whenever possible.

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This report describes an 81-year-old male with a history of posterior cervical fusion who developed dysphagia following surgical treatment for lateral oropharyngeal wall cancer and lower gingival cancer. Indirect training, such as teaching the patient how to regulate the tension in the neck muscles, enabled him to keep his chin down, thus resulting in a short-term improvement of the dysphagia symptoms. Chin tuck, also known as chin down, has no clear anatomical definition, and it includes various positions in clinical practice because the cervical spine is involved in multiple reflexes. Guidance was provided for a chin tuck position (flexion of the upper cervical spine and extension of the lower cervical spine) with regard to the trigeminocervical reflex. An evaluation of swallowing function following confirmation of the anatomical position on X-rays revealed the importance of upper cervical spine flexion. This finding was consistent with the patient's history of posterior cervical fusion. The effects of chin tuck are currently being investigated according to different definitions. Further guidance and investigations of the effects based on an anatomical definition of chin tuck is necessary for a more accurate evaluation of such patients.

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Four elderly patients, complaining of an abnormal sensation in the pharynx and/or larynx during swallowing, but without any aspiration of food, received training designed to alleviate their symptoms. The findings of pharyngoesophageal fluoroscopy after training were compared with the pre-training findings. During the training, each patient was instructed to keep the mandible pulled strongly towards the chest, and the trainer manually pulled and stretched the patient's mandible for a while, with the patient's chin immobilized by the trainer's hand. This manipulation allowed the time needed for the passage of contrast material to decrease in 2 cases. Furthermore, following this training, the height of the thyroid cartilage at rest thus became higher than the pre-treatment level in all 4 patients. An improvement in the closure of the pharynx in association with the soft palate was also noted. Although this is a very simple method of training, it is promising as a means of both alleviating a lower-than-normal position of the larynx and suppressing the aspiration of food which is caused by this abnormality.

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In this article, the authors describe a method of laryngeal suspension to prevent the formation of dead space and postoperative infection. In the surgical treatment of oropharyngeal carcinoma, three patients were treated by laryngeal suspension in order to avoid postoperative dysphagia. Regarding the laryngeal suspension procedures, absorbable suture materials were used for thyro-mandible sutures. Each suspension suture was placed dorsal to the mandible and thyroid cartilage to prevent the formation of any dead space. No patient demonstrated any severe complications related to the laryngeal suspension procedures. All 3 patients were able to eat normal diets postoperatively.

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There are several procedures to prevent intractable aspiration, however, most such patients with aspiration still tend to have severe complications and thus are considered to show a poor risk for aggressive surgery. As a result, minimally invasive and more reliable procedures are thus required for such cases. We introduced a modified procedure of the technique of Montgomery. The frontal neck skin is incised vertically. The thyroid cartilage perichondrium is incised in the midline and then retracted widelyon both sides. Next, the anterior thyroid lamina is removed at the crico-thyroid joint. After the laryngeal lumen is opened by a laryngofissure, the glottis is denuded of the epithelium circumferentially at the level of the false vocal cord from the petiole of the epiglottis to the interarytenoid mucosa. The petiole and interarytenoid mucosa are sutured in an anterior-posterior direction and then the laryngofissure is closed with strap muscles. The patient was a 66-year-old male who complained of intractable aspiration of refluxed bile due to a gastrectomy and medullary infarction. He was transferred to our hospital to undergo surgery that would correct the troublesome aspiration. However, his preoperative condition continued to worsen, with an unabated flow of emesis into his lungs and he therefore developed severe respiratory failure. General anesthesia was difficult to administer, and therefore we performed a supraglottic closure under local anesthesia. After surgery, his general condition rapidly improved, and he was able to be transferred to a rehabilitation facility without any major post-operative complications. This procedure is therefore considered to be useful for the patients without the need to perform a reverse operation due to presence of underlying intractable or progressive diseases.

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The present study was conducted to evaluate the effectiveness of capsaicin troche for age-related swallowing dysfunction. Ten healthy elderly volunteers who showed a decreased swallowing function when they were examined by either videoendoscopy or videofluorography participated in this study. They included 4 males and 6 females, and their ages ranged from 64 to 78 years with an average age of 70.0 years. They were administered capsaicin trochisci (1.5μg/tablet, 2 tablets/day) for one month. Thereafter, their swallowing functions were examined again using a self-reported questionnaire, videoendoscopy and videofluorography. The self-reported questionnaire and videoendoscopy showed a general improvement in the swallowing function. Videofluorography demonstrated a significant decline of the pharyngeal transition time of the bolus, although the laryngeal elevation delay time was stable. These results showed that the swallowing function in elderly adults improved after the administration of capsaicin troche tablets, thereby suggesting the possible therapeutic effectiveness of capsaicin troche for the treatment of age-related swallowing dysfunction.

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Dysphagia has been conventionally evaluated primarily by mechanical functions, while the evaluation of sensory functions has been largely neglected. A newly developed flexible laryngoscopic laryngopharyngeal sensory test was performed in 35 patients with dysphagia in whom pharyngeal bolus retention was demonstrated by a videofluorographic study of swallowing. The flexible laryngoscope (XENF-DP) and the probes used in the test were jointly developed with the Olympus Corporation. There were 4 types of probes, and the test sites were touched beginning with the one with the smallest diameter, and thereafter the probes were serially changed to larger ones. The response was judged to be positive when the patient felt a sensation, which supported the objective confirmation of the laryngeal adductor reflex. The test sites included the laryngeal surface of the epiglottis, and, if possible, the bilateral arytenoid regions. The interrelations among the sensory threshold of the larynx, the perception of pharyngeal retention, food aspiration, salivary aspiration, and a history of pneumonia were all examined. The correlation between the laryngeal sensibility and the perception of pharyngeal retention and salivary aspiration were also probed. According to the type of dysphagia, laryngeal sensibility was reduced in all subjects with pseudobulbar palsy. A larger number of subjects should be examined in the future and the findings should then be clinically applied to determine the correlation between a reduced laryngeal sensibility and either aspiration or pneumonia from a preventive viewpoint.

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We herein report a case of late onset pharngeal perforation and aspiration pneumoniae after reconstruction of the cervical spine using an anterior cervical palate. A 72-year-old male had been treated by radiotherapy and chemotherapy for malignant lymphoma of the cervical spine followed by reconstruction of the cervical spine using an anterior palate. A few years thereafter, however, he was hospitalized with aspiration pneumoniae. A laryngoscopic examination revealed that the cervical plate has cropped out from the posterior wall of the hypopharynx and saliva had thus become pooled in the right piriform sinus. In addition, X-ray radiography showed the palate to have loosened. Video-fluorography revealed stenosis of the right hypoparyngeal cavity at the level of the cricopharyngeal muscle. After removing the cervical palate and closing the pharyngeal perforation, cicatricial stenosis of the hypopharyngeal cavity and barium aspiration were observed by video-fluorography. The patient was then treated by a balloon catheter method and his swallowing function thereafter improved. This method was therefore found to be useful for the treatment of dysphagia caused by cicatricial stenosis of the cricopharyngeal segment.

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The cortical theta, alpha, beta, and gamma ERD/ERS were investigated before command swallowing (CS) and voluntary swallowing (VS), in six healthy left handed male volunteers, using magnetoencephalography. CS was signaled by a light signal, while VS was self initiated. Five volunteers showed the alpha ERD and beta ERD areas in CS and VS to be similar in the parietal lobe from 0.5 to before the start of swallowing. The function of the parietal lobe may thus be necessary for the control of swallowing as well as the beta ERD areas in the motor and premotor area. Four volunteers showed a difference in the area of theta ERD between CS and VS in the right medial and inferior prefrontal gyrus and temporal pole from 1.5 to 1.0 s before swallowing. These observations may suggest a difference between CS and VS in cognitive processing before swallowing.

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