I reviewed the literature in regard to progress related to pediatric dysphagia abroad, primarily in the United States, during the past 10 years and have summarized the trends.
There are reports of feeding problems being observed in 25％ to 45％ of children as a whole, and in 33％ to 80％ of children with developmental delays, and the number of children with feeding and swallowing disorders has presumably increased as a result of advances in medical technology.
The typical abnormal findmgs observed in pediatric dysphagia are varied and include oral motor dysfunctions, food selectivity and refusal, difficulty in maneuvering boluses, aspiration, and gastroesophageal reflux disease. Oral motor dysfunctions are seen in especially high percentages of children with cerebral palsy and children with Down syndrome, whereas oropharyngeal dysphagia is not seen in children with the autistic spectrum. Their dysphagia is attributable to perceptual problems or gastrointestinal problems of unknown etiology, and they are more likely to exhibit selectivity of food type and texture.
A variety of questionnaires and a scale for systemic observation of breast and bottle feeding behavior have been developed as assessment methods. A videofluoroscopy swallow study (VFSS) and fiberscopic endoscopic evaluation of swallowing (FEES) have become widely adopted as precise examinations, and various testing manuals and guidelines have been published. Numerous comprehensive assessment forms have also been proposed.
In terms of intervention methods, reports have accumulated on modification of the texture and shape of foods and liquids, adequate formula selection for oral and non-oral feeding, modification of the meal environment, improved motor function and sensory function training, appropriate selection of nipples and bottles, optimal positioning, cheek and chin support, pacing, training in spoon, glass, and straw use, chewing training, feeding schedules, contingency management, shaping, use of gastric acid secretion blockers for gastroesophageal reflux disease, surgical management, etc. There is also a trend toward actively addressing the rehabilitation of young infants with feeding disorders in neonatal intensive care units.
【Purpose】The soft palate (SP) rises as the jaw opens and it falls as the jaw eloses during mastication. During swallowing, the SP elevates to seal the nasopharynx while jaw is closed. We examined the amplitude of SP movement and the temporospatial relationship between SP and jaw movement during feeding using cross-correlation analysis.
【Methods】Videofluorography in lateral projection was performed on 15 healthy volunteers (9 male and 6 female, mean 25 years old) eating 6 g of banana, chicken spread and cookie. A small radiopaque marker at the tip of a thin flexible rubber tube was passed transnasally to the superior surface of the SP. Additional markers were glued to upper and lower teeth. The SP and jaw marker positions were measured frame by frame and transformed into Cartesian coordinates. A feeding sequence was divided into three stages：food processing, oropharyngeal aggregation time, and swallowing. The highest and lowest points of SP movement were measured for each stage. The relationships between motions of the SP and jaw were quantified with cross-correlation functions.
【Results】There was cyclic motion of the SP in 50% of jaw cycles during processing and oropharyngeal aggregation cycles, with the lower jaw descending as the SP rose. The frequency of SP movement differed significantly among subjects (P＜0.001), but not among stages or foods. The amplitude of SP elevation gradually increased as the sequence progressed from processing to swallow (P＜0.001), The amplitude was higher with cookie than banana or chicken spread (P＜0.05). Cross-correlation coefficients were negative between motions of the jaw and SP during processing and aggregation (mean R ＝ －0.41 ± 0.24 and －0.42 ± 0.18, respectively). Jaw opening followed SP elevation by 0.10s during processing and 0.07s during aggregation. In contrast, SP-Jaw movement cross-correlations in swallowing were positive (mean R ＝ 0.49 ± 0.30) and SP elevation followed jaw closure by 0.13s.
【Conclusion】This study confirms and quantifies the temporospatial linkage between SP and jaw motion reported previously. The contrasting temporal linkages during mastication and swallowing suggests that different neural mechanism generate the motions of the SP during these two behaviors. The increase in SP displacement in later cycles may facilitate bolus transport by opening the fauces, and additionally provide a route for odors to reach the nasopharynx.
【Objective】Videofluoroscopic examination of swallowing is widely performed to assess dysphagic function. However, the results are not necessarily linked to the food texture of daily meals because barium sulfate changes the texture of food. Consequently, standardized test foods are needed. In this study, we prepared test food the model for which was based on Seirei Mikatahara General Hospital's stepwise swallowing diets. This hospital is one of the most experienced hospitals with respect to nutritional management for dysphagic patients. Object grades are Grade 1 to Grade 3, which provide for severe dysphagic patients among the five grades of stepwise swallowing diets. As the grades rise, hardness becomes harder and softer. So we also investigated the concentrations of gelling agents for test food that were suitable for both the lower limit and upper limit for each grade.
【Method】We used liquid barium diluted 50 w/v％ with ion exchanged water and prepared test food using various concentrations of commercial gelling agents. Texture was measured by CREEP METER, and the hardness, adhesiveness, and cohesiveness of the food were calculated.
【Result】Barium jelly indicated a significant correlation between temperature and hardness. Moreover, there was significant correlation between hardness and concentration. Finally, we determined the lower limit and upper limit for each grade of the test food. The concentration of gelling agents in Grade 1 was 0.95％ and 1.60％, in Grade 2 was 0.65％ and 1.95％, and in Grade 3 was 0.50％ and 2.20％, respectively.
【Conclusion】We determined the concentrations of gelling agents for test foods that were suitable for stepwise swallowing diets.
The aim of this study was to evaluate the preventive effects of perioperative oral care on postoperative pneumonia and to clarify the risk factors that predict postoperative pneumonia in patients with esophageal cancer.
【Methods】Fifty-three patients (49 males and 4 females, 63 ± 6.7 years old) who underwent extended esophagectomy in Kinki University Medical Hospital were retrospectively reviewed. Postoperative pneumonia developed in 9 patients (17.0％). The 53 patients were divided into two groups depending on whether professional care was taken for oral hygiene (oral care (＋) group, n ＝ 29) or not (oral care (－) group, n ＝ 24), Perioperative factors including oral hygiene were compared to predict postoperative pneumonia.
【Methods】In the oral care (＋) group, pneumonia patients were not found after postoperative day 17. However, in the oral care (－) group, pneumonia patients were found even after postoperadve day 17. In patients who underwent extended esophagectomy with three field lymph node dissection, oral care tended to diminish the frequency of postoperative pneumonia and shorten both the postoperative duration to start oral feeding and postoperative stay. No single variables were identified that could predict postoperative pneumonia after esophagectomy.
【Conclusion】These results indicate that postoperative pneumonia after esophagectomy is induced by multiple factors and oral care is an effective treatment tool to prevent it. Perioperative treatment of patients with esophageal cancer should be carried out by a team of professionals, including oral care staff, who work together in a coordmated fashion to provide high-quality care.
We present a newly developed gelling agent that can gelatinize foods over a wide temperature range. The textual characteristics of typical Japanese foods (rice gruel, miso soup and green tea) were investigated based on mechanical evaluations of physical properties (hardness, cohesiveness and adhesiveness) and sensory evaluation (palatability, stickness, viscosity, residual sensation and ease of swallowing). The major findings were as follows：
1. Rice gruel was gelatinized at different temperatures (30‐55℃). There were no differences in hardness, cohesiveness and adhesiveness among the different temperatures, and the physical properties of rice gruel were suitable for all samples. Sensory evaluations showed that all parameters were favorable at the temperatures tested.
2. Liquid foods (miso soup and green tea) were gelatinized at relatively high temperatures (75℃), The changes in texture were then examined as temperature was decreased. Although hardness fluctuated slightly at temperatures of 20‐50℃, it was markedly below the standard set by the Ministry of Health, Labor and Welfare. Cohesiveness and adhesiveness were stable and were not affected by temperature. Sensory evaluations showed that all parameters were favorable at the temperatures tested.
3. Liquid foods were gelatinized at relatively low temperatures (10℃), and the changes in texture were determined as temperature was increased. Although hardness fluctuated slightly at temperatures of 10‐30℃, it was markedly below the standard set by the Ministry of Health Labor and Welfare. The degree of fluctuation in cohesiveness and adhesiveness due to increases in temperature were relatively small, and the properties of all gelatinized foods were suitable. Sensory evaluations showed that all parameters were favorable at the temperatures tested.
These findings suggest that the present gelling agent can maintain suitable textural quality when rice gruel is gelatinized at different temperatures or when liquid foods are gelamized at a specific temperature and then stored at another temperature. This study demonstrated the convenience and usefulness of the present gelling agent in allowing dysphagic patients to maintain sufficient calorie and water intake on a daily basis.
We report the case of a 47-year-old male patient who presented with dysphagia hoarseness, and central-type hypoventilation due to the recurrence of a medullary hemangioblastoma. lnitial treatment included a tracheostomy and the total surgical extirpation of the tumor. As hypoventilation subsided, the tracheostomy was closed, but re-tracheostomy was soon required due to the repeated occurrence of aspiration pneumonia. Videofluorographic examination of the patient's swallowing revealed mis-swallowing due to impairment of the swallowing reflex, resulting from abnormal pharyngeal peristalsis, and failed relaxation of the upper esophageal sphincter (UES). Moreover, no cough reflex was evident, As rehabilitation exercises over a 6 month period demonstrated no significant improvement in either swallowing ability or cough reflex, a total laryngectomy was performed and an indwelling voice prosthesis was placed to prevent continued aspiration pneumonia and preserve phonation. The postoperative course was uneventful, and the subject was able to ingest normally without any need for tube feeding or intravenous alimentation, and could also successfully communicate using the voice prosthesis.
While most operative procedures that prevent mis-swallowing tend to sacrifice phonation, the method reported in this case has the merit of successfully combining the two without compromising either.
Head-neck cancer patients with dysphagia may have difficulties in performing Shaker's head-raising exercise because of physical consequences of neck muscle weakness and surgical intervention. We report newly developed muscle strengthening exercises and treatment progress for these patients. Two cases were presented. A 62-year-old woman with esophageal cancer and a 56-year-old woman with thyroid cancer underwent surgical interventions and behavioral treatment for dysphagia. Following the radical operations, both patients showed severe pharyngeal dysphagia associated with breathy hoarseness, weakness of neck muscles, and restricted laryngeal movements. A Shaker's head-raising exercise was practically impossible in a supine position. A videofluorograpic examination of swallowing showed aspiration and limited laryngeal excursion. The neck muscle strengthening exercises were composed of isotonic and isometric exercises of head flexion with and without manually applied resistive force in an upright and reclining positions. Pushing exercises were included to improve the laryngeal closure. To facilitate safe and efficient feeding, compensatory techniques including super-supraglottic swallowing and chin-down posture were used. Both cases were fed orally for all the meals within two months following the treatment, and dysphonia and laryngeal elevation was improved. Thus, our manual resistive exercises were considered effective for dysphagic patients who have difficulties with voluntary head-raising movement.