We evaluated the effectiveness of rehabilitation therapy for dysphagia due to head and neck diseases by presenting 3 representative cases and also reviewing the previous pertinent literature. The goal of such rehabilitation therapy is to effectively use the remaining function and to learn compensatory swallowing maneuvers. In patients with head and neck disease, various kinds of techniques to compensate for individual swallowing dysfunction can be introduced for rehabilitation purposes because the systemic activity and consciousness level of such individuals are generally well maintained. This is advantageous for obtaining a successful improvement of the swallowing function. We also stress the early introduction of oral intake training after the onset of dysphagia. Owing to this well designed rehabilitation program, the majority of the patients can therefore resume oral consumption. In some patients, however, severe dysphagia makes it impossible to achieve successful intensive rehabilitation. In such patients, surgical intervention to improve the symptoms of dysphagia should be considered instead of merely continuing long-term ordinary rehabilitation.

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The objective of this study was to prepare homemade rice gruel coated with a thickener. It is difficult to maintain the freshness of rice gruel when it is stored for more than 4 hours with refrigeration. However, the use of a thickener may keep the rice gruel fresh for a longer period of time. In the present study, we performed a sensuality examination, especially a taste-test. Pure water, city water and mineral water were used for preparing steamed rice. The taste test revealed that the steamed rice prepared using pure water had the best taste. Furthermore, the homemade rice gruel that was coated with a thickener had the freshest taste. The homemade rice gruel with 3 % salt was the most delicious. We measured the hardness and tenacity of the rice gruel with a mechanical device. The measurements revealed that the homemade rice gruel that had been refrigerated for 4 hours was as fresh as gruel immediately after cooking. Furthermore, this rice gruel had a good score according to the taste test. The homemade gruel prepared using pure water and a thickener is an excellent health food and it is suitable for individuals with dysphagia.

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Placing patients in a reclining position is thought to be a compensatory method to improve swallowing difficulties. The anatomical alignment between the airway and esophageal position in the reclining position reduces the possibility of aspiration, and this may be advantageous in patients with delayed swallowing reflex. Therefore, it is used for most patients with dysphagia ; however, no study has yet compared the delay of the swallowing reflex with the inflow of the alimentary bolus and the effectiveness of the reclining position for such patients. The parameter laryngeal elevation delay time (LEDT) was used to clarify the efficacy of the reclining position. The LEDT is significantly extended in liquid deglutition in comparison to jelly deglutition. The LEDT was increased in the reclining position in swallowing liquid with low viscosity. The risk of aspiration will become higher because this tendency is greater in patients with poor elicitation of pharyngeal swallowing, and attention should be paid to such patients in the reclining position. In contrast, the transfer from oral cavity to the pharynx became smoother with the deglutition of solid material such as jelly in patients that had difficulty in the oral stage. Therefore, the reclining position may be effective only in the swallowing of material with a slow inflow velocity into the pharynx.

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Gelatinous meal is clinically available for patients with dysphagia so that it is easier to cough and exhaust it from the airway than liquid. It is supposed that the inflow of the jelly to the pharynx is slower than that of the liquid due to its physicality. However, there have not been any studies that have examined the differences between liquid and jelly in terms of deglutition. We sought to elucidate this difference by using two kinds of contrast media of known viscosity, and by using laryngeal elevation delay time (LEDT) as a parameter which has been useful for evaluating the pharyngeal stage. Our results indicate that LEDT can be successfully used to detect these differences, and there is a possibility that LEDT, which is measured by low viscosity contrast media, is an effective parameter for evaluating the delay of pharyngeal stage, and the LEDT can thus be used as a parameter to elucidate the properties of gelatinous meals available for patients with dysphagia.

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A 79-year-old female subject presented with slowly progressing dysphagia and an impairment of the bilateral upper esophageal sphincter opening. The patient was suspected of having myopathy by the pathological findings of cervical and cricopharyngeal muscles, but a diagnosis was not definitively according to the diagnostic criterion of known diseases. The patient may have myopathy localized in the cervical and pharyngeal muscles, as was suggested by the patient's past medical history. The investigation of a larger series of similar cases will be required to further define this disease. Cricopharyngeal myopathy is considered to be an effective therapy, but an earlier diagnosis and treatment are required, which should be based on the development of both new testing and diagnostic criteria.

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The present report describes a 61-year-old female patient who developed dysphagia after undergoing the surgical removal of cerebellar meningioma. The patient was unable to swallow because of paralysis involving the right vocal cord. The patient underwent the injection of fat into the paralyzed vocal cord and was fitted with a palatal lift prosthesis followed by rehabilitation. The patient thereafter demonstrated a significant improvement in here swallowing ability and could vocalize words more clearly than before undergoing this surgical procedure.

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Laryngeal suspension (LS) and cricopharyngeal myotomy (CM) together provide very effective surgical treatment for some dysphagia patients. However, they have a limited effectiveness because they are associated with a risk of aspiration. Disabled patients often have impaired airway clearance, in association with severe respiratory problems or immuno-insufficiency. This report presents the case of a patient treated with epiglottoplasty (Biller's technique) after LS and bilateral CM. The patient presented with severe dysphagia caused by bulbar infarction. He was initially scheduled to undergo rehabilitation, and underwent LS and bilateral CM. He had an uncomplicated postoperative course, but then he experienced recurrent multicycle spinal compression fracture and asthma, and his general condition thereafter gradually deteriorated. He became susceptible to aspiration pneumonia. He was treated with epiglottoplasty, and survived the bout of aspiration pneumonia and was thereafter able to resume an unrestricted diet without losing his voice.

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Although cancer of the base of tongue in the oropharynx region is not as responsive to chemoradiotherapy (CRT) as lateral wall type, it is nevertheless effective in some cases. Moreover, surgery for cancer of the base of tongue is sometimes very difficult, and may reduce the patient's swallowing function. Therefore, the choice of the best treatment method for cancer of the base of tongue is very important. Therefore, induction chemotherapy (IC) is initially performed for not only with cancer of the base of tongue but also for other head and neck squamous cell carcinoma cases in our department. Either CRT or surgery is performed after IC, depending on the effect of the IC. This report presents a case of base of tongue cancer which was successfully treated by a function-preserving operation after IC. The procedure focused on the complete resection of the tumor and preserving the functions. The patient then underwent dysphagia rehabilitation after surgery. The patient could eat a normal diet and was cancer-free after regaining good swallowing function following rehabilitation. The selection of definitive therapy is very important for the treatment of cancer of the base of tongue. Chemoselection after IC is a good tool for head and neck cancer treatment, because of its chemo-radio sensitivity. The degree of surgical difficulty, however, is different for each case.

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We evaluated the indications for surgery for the improvement of deglutition from 23 patients with dysphagia who had undergone surgical treatment, such as a cricopharyngeal myotomy, a laryngeal suspension, etc. Thirteen patients (56%) had restored oral food intake post-operatively, while 10 (44%) patients needed tube feeding. Six of 7 patients who showed decreased pharyngeal sensation needed tube feeding. There was a significant correlation between the decreased pharyngeal sensation and outcomes (p < 0.05). In addition, there were 3 patients who could not cough up phlegm, 3 patients who had undergone a gastrectomy and 2 patients with severe cardiopulmonary disease. The patients with these factors (which often overlapped) also needed tube feeding. These patients were not good candidates for these surgeries.

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For intractable aspiration patients presenting at Kawasaki Medical School Hospital, total laryngectomy was performed in 12 patients from 1991 to 2000 and either laryngo-tracheal separation or tracheo-esophageal anastomosis, namely Lindeman's operation, was performed in 10 patients from 2002 to 2009. We evaluated the surgical results and postoperative conditions between the patients undergoing total laryngectomy and Lindeman's operation. No complications were noted intraoperatively for any of the patients. The average duration of surgery also showed no significant difference between the two groups. The average volume of blood loss during Lindeman's operation was significantly less than that for total laryngectomy. In addition, postoperative fistula occurred in two patients undergoing total laryngectomy, while it only occurred in one patient receiving Lindeman's operation. In conclusion, Lindeman's operation is considered to be an effective treatment for intractable aspiration, thereby improving the quality of life for both the patients and their families.

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We examined whether or not postoperative dysphagia could be predicted pre- or postoperatively in patients who underwent cardiovascular surgery. Patients and Methods : The study was conducted involving 20 patients (14 males and 6 females) whose nutritional management was performed by the nutrition support team (NST) in our hospital because they had difficulty in oral intake after cardiovascular surgery. They were divided into two groups : group A consisted of 8 patients in whom the period from surgery to the final food-intake was less than 1 month ; and group B consisted of 12 patients in whom the period was 1 month or longer, leading to a marked problem with postoperative dysphagia. Comparisons between both groups were conducted. Results : When a patient met four or more out of eight items of the following as factors causing dysphagia after cardiovascular surgery were applicable, dysphagia was likely to occur : age (70 years old or older), obesity with a body mass index (BMI) ≤ 25 or low body weight with a BMI < 18.5, a markedly reduced cardiac function (EF ≤ 40%), a history of cerebral infarction, that of respiratory disease, presence or absence of emergency surgery, aortic surgery, and prolonged surgery (10 hours or longer). The factors of emergency surgery, obesity, and aortic surgery out of the above items were considered to have an influence on dysphagia. A correlation between scores of these eight items and the number of days from surgery to the final food-intake was noted. The results also revealed that intervention by NST for dysphagia patients after cardiac surgery was effective. Thus, it was considered to be necessary for preoperative information to be provided sufficiently and appropriate and prompt measures to be taken for patients who were expected to be at risk of postoperative dysphagia based on their preoperative scores.

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We herein present a case where oral food intake was restored by long-term swallowing rehabilitation in a patient with hypopharyngeal carcinoma who presented with severe dysphagia after partial pharyngectomy. A seventy-year-old male received an extended partial pharyngectomy with preservation of the larynx, bilateral neck dissection, laryngeal elevation, and tracheotomy. Thereafter, he showed intractable swallowing disturbance, and consulted our hospital for further treatment of dysphagia. Evaluations of swallowing function on his admission showed 0 time/30 seconds of repetitive saliva swallowing test, paralysis of the right vocal fold, sensory dysfunction of the pharyngolaryngeal mucosa, and severe salivary pooling in the vallecula and piriform sinuses. Videofluorographic examination showed delayed initiation of the swallowing reflex and limited elevation of the larynx in the pharyngeal swallowing stage, which resulted in significant aspiration. Through intensive rehabilitation for these dysfunctions, he started training for oral intake in the 14th week after the operation, had a soft diet in the 17th week, and ate an ordinary diet sufficiently in the 35th week after the surgery. In this case, the sensory and motor functions of the pharyngolaryngeal region were considerably impaired after the surgery. However, precise assessment of dysphagia and long-term intensive rehabilitation by speech-language-hearing therapists in cooperation with otolaryngologists resulted in sufficient recovery of swallowing function.

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We previously reported that several rounds of exercise (isometric contraction) of the anterior neck muscles above and below the hyoid bone and the sternomastoid muscle, while supporting the mandible, can improve the swallowing function. Isometric contraction is a training maneuver expected to increase the muscular strength in short periods of time. Eleven elderly individuals (age : 60-88) underwent self-training with this maneuver immediately before each meal and the efficacy was evaluated 2-3 weeks later. During the analysis of the results, the repetitive saliva swallowing test score changed from 2.7 (± 1.2) before training to 6.2 (± 1.6) after training. On plain lateral neck X-ray, the chin-hyoid bone distance decreased by 11.1% and the chin-thyroid cartilage distance decreased by 8.4%. The sternum-thyroid cartilage distance increased by 12.0%. Therefore, the location of the hyoid bone and thyroid cartilage, which had become closer to the sternum as a result of aging, was corrected to become closer to the chin. This change is expected to improve swallowing by promoting an earlier start of swallowing.

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The tongue-hold swallow (THS) is a swallowing exercise that potentially facilitates anterior bulging of the posterior pharyngeal wall (PPW) in patients with reduced contact between the base of tongue (BOT) and the PPW. However, its actual therapeutic benefit has only rarely been evaluated. This paper examined the effects of THS in a patient who had received three months of THS-only therapy for his reduced BOT-PPW contact during the pharyngeal stage of swallowing. An analysis of videofluorographic images revealed improved BOT-PPW contact after therapy. In addition, the results indicated the possible enhancing effects of THS upon posterior movement of the BOT.

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The present study examines the utility of isometric lingual exercise as a means of strengthening the suprahyoid muscles in 10 healthy volunteers (mean age, 27.4 years ; range, 23-34 years). We measured the maximum tongue pressure of each subject using the Iowa Oral Performance Instrument (IOPI). We then measured the electromyographic activity of the suprahyoid muscles during a tongue press with a load intensity of 20%, 40%, 60% and 80% of maximum tongue pressure while providing feedback about the tongue pressure on a monitor. We also compared the electromyographic activity of the suprahyoid muscles during the tongue press using maximum tongue pressure, the head lift exercise, the Mendelsohn maneuver and tongue protrusion. Increasing tongue pressure resulted in increased electromyographic activity of the suprahyoid muscles, and the magnitude of the resultant electromyographic activity differed significantly with each load. Among the various training movements, lingual exercise with maximum tongue pressure maximally increased the electromyographic activity of the suprahyoid muscles. These results indicate that isometric lingual exercise is a useful method for strengthening the suprahyoid muscles.

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A retrospective study of videofluorography in patients with an abnormal sensation in the throat was performed. We focused on the findings related to aspiration, pharyngeal clearance, and the presence of an esophageal web, cricopharyngeal bar, pharyngeal pouch, esophageal diverticula, or a cervical osteophyte. The patients consisted of 126 males and 118 females. Aspiration was found in 13 cases (5.1%). Decreased pharyngeal clearance reached 36.5% more frequently in males. An esophageal web was found in 12.3% of patients. A cricopharyngeal bar, pharyngeal pouch, esophageal diverticulum and a cervical osteophyte were identified in 5.7%, 4.9%, 3.3%, and 16.8% of the patients, respectively. These results showed that functional dysfunction or organic lesions in the pharyngolaryngeal region might be responsible for an abnormal sensation in the throat. We emphasize the importance of videofluorographic examinations for patients complaining of an abnormal sensation in the throat.

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Primary cricopharyngeal dysphagia is an uncommon disease associated with a swallowing disturbance at the level of the upper esophageal sphincter and it is characterized by the presence of a prominent cricopharyngeal bar, which can be observed by a radiographic swallowing study. We herein report two cases of primary cricopharyngeal dysphagia that showed different clinical courses. Case 1 was an 80-year-old female who presented with a history of difficulty in swallowing of several years duration. Her swallowing symptoms worsened after the first visit and, as a result, she had lost weight 9.5 kgs (from 34 kg to 24.5 kg) in the following 22 months. She underwent a cricopharyngeal myotomy, and her swallowing symptoms thereafter improved. A histopathological study of her cricopharyngeal muscle showed myopathic changes including atrophy and a decreased number of muscle fibers, interstitial fibrosis, lipomatosis, and lymphocyte infiltration. Case 2 was a 61-year-old male who presented with slight difficulty in swallowing of 4 years duration. While we have followed him for more than 7 years, his swallowing symptoms and findings in radiographic studies have shown no remarkable worsening. Consequently, he has survived to date for 11 years and continues to only have slight difficulty in swallowing. The clinical courses of primary cricopharyngeal dysphagia are therefore likely considered to be diverse, and the treatment strategies should thus be different depending on each specific case.

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Videoendoscopic examination has many advantage for evaluating the swallowing function. However, this method has one serious fault, namley it is not possible to obtain an image at the precise moment of swallowing. Only a whitish image is observed, the so-called “white out”. This study attempted to simultaneously measure swallowing pressure, to evaluate the swallowing function at the moment of “white out” Patients with unilateral vocal fold palsy were observed before and after thyroplasty. white-out is the only image visible at the moment of swallowing. The swallowing pressure at the moment of swallowing was improved after thyroplasty. The manometric examination is thus condidered to be a good tool for objectively evaluating the swallowing function at the moment of swallowing.

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Objective : We devised a new analytical method to evaluate swallowing dynamics from videofluorography (VF). Subjects and Methods : For 2 healthy subjects and a patient with Parkinson's disease (PD), we examined VF using liquid barium. We put 9 markers on the pharynx in VFG clips using two-dimensional motion analysis software and measured movements of these markers. We assessed changes in the lower oropharynx and hypopharynx, which were surrounded by markers. Results : In healthy subjects, the lower oropharynx moved sequentially ; it first expanded, then contracted, and finally relaxed. The hypopharynx began similar movements, 0.2-0.3 seconds later than the lower oropharynx. In the PD patient, contraction of the pharynx occurred ; however, the lag between movements of the lower oropharynx and those of the hypopharynx was shorter than in healthy subjects. The PD patient did not aspirate but residue was visible in the epiglottic vallecula and piriform fossa. Conclusion : Temporally-programmed swallowing movements appeared to cause propulsion of food, allowing healthy subjects to transport liquid from the pharynx to the esophagus. In the PD patient, the local pressure gradient in the pharynx appeared to be insufficient because of impaired coordination. Our method was useful for evaluating from VFG the sequential pharyngeal movements during swallowing.

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A speech therapist performs swallowing rehabilitation in this hospital because concurrent chemoradiotherapy (CCRT) for head and neck cancer is commonly associated with, dysphagia. An evaluation of oral mucositis and dysphagia after CCRT was conducted to determine the relationship between swallowing rehabilitation and swallowing disability. A total of 51 patients (44 males and 7 females) with a mean age of 63 years (range, 39 to 80), underwent CCRT with or without neck dissection between April 2008 and November 2009. Oral mucositis and dysphagia were graded at the end of CCRT according to CTCAE, version 4.0. Seventeen of 51 patients underwent swallowing rehabilitation, exercise and education on muscle strengthening programs before and during CCRT. The average grades of oral mucositis of patients with nasopharyngeal, oropharyngeal, hypopharyngeal, and laryngeal cancer patients were 1.8, 2.1, 1.8, and 0.8, respectively. There was a lower incidence of oral mucositis in patients with laryngeal cancer than in those with oropharyngeal or hypopharyngeal cancer. The average grades of dysphagia of patients with nasopharyngeal, oropharyngeal, hypopharyngeal, and laryngeal cancer were 2.4, 2.7, 2.2, and 1.2. Dysphagia was most severe in the patients with oropharyngeal cancer, while it was minimal in those with laryngeal cancer. Seventeen diligent patients that underwent swallowing rehabilitation every day rarely developed severe dysphagia.

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Objective : Supracricoid Laryngectomy with Cricohyoidoepiglotto-pexy (SCL-CHEP) is a laryngeal preservation surgical modality for laryngeal carcinoma. We have performed this procedure since 1997. We herein report the swallowing recovery of a patient who received SCL-CHEP 12 years ago. Case : A 70-year-old male with glottic cancer (rT2N0M0) received SCL-CHEP in November 1997. The swallowing functions recovered in the patient after one month of intensive rehabilitation. Under videofluorographic examination, aspiration disappeared after the swallowing rehabilitation. The patient's past history of interstitial pneumonia did not affect the post-operative functions, such as aspiration pneumonia. The patient received abdominal endoscopic surgery under general anesthesia seven years after SCL-CHEP ; this did not affect the patient's swallowing function. The patient is over 80 years of age and maintains the ability to take regular meals and water within 20 minutes. Discussion : In this particular case, aspiration was not evident in recent examinations. In general, swallowing function deteriorates with increasing age. In the present case, a good swallowing function was maintained. This demonstrated that a good swallowing function following SCL-CHEP can be maintained in patients who are over 80 years of age.

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