【Purpose】We conducted videoendoscopic evaluation of swallowing (VE) in visiting dental treatments, then investigated the problem of nutrition and the effect of immediate intervention of VE for in-home or nursing-home dysphagia patients.
【Subjects and Methods】We conducted VE for 265 dysphasia patients (139 males, 126 females, average age 75.5). Nutrition was evaluated as：tube feeding (T), tube feeding ＞ oral feeding (T＞O), tube feeding ＜ oral feeding (T＜O), oral feeding needing safe adjustments (Oa), and oral feeding not needing adjustment (O). The present nutrition and recommended nutrition by VE were compared. The relationships between nutrition and the past existence of aspiration pneumonia were investigated.
【Results】(1) Most of the subjects were recommended to raise nutrition levels from T to T＞O. Most of the subjects with low nutrition levels were recommended to raise the level from O to Oa. (2) Many subjects who were recommended to raise the level from T to T＞O had past aspiration pneumonia. Some of the subjects who were recommended to raise the level from O or Oa to T＞O or T had past aspiration pneumonia.
【Discussion】 (1) There were many dysphagia patients whose nutrition disagreed with their present swallowing functions, and they were overestimated or underestimated. (2) The selection of nutrition was considered to be decided by not the present swallowing function but their past aspiration pneumonia.
Although there are numerous screening tests for dysphagia, they mostly focus on aspiration but silent aspiration (SA). We studied the usefulness of a cough test done by inhaling citric acid to screen for SA. Participants in this study consisted of 204 patients (131 men and 73 women) whose average age was 69.90 ± 11.70. They were suspected of having dysphagia and were administered a cough test and VF or VE. They inhaled a mist of 1.0％ citric acid-physiologic saline orally for 1 minute using an ultrasonic nebulizer. A medical assistant observed the number of times each patient coughed：more than five coughs was considered as negative (normal), while less than four coughs was regarded as positive. Using diagnosis of the VF or VE as standards, the sensitivity of the cough test to detect SA was 0.87, the specificity was 0.89, efficiency was 0.89, the positive predictive value (PPV) was 0.74, and the negative predictive value (NPV) was 0.95. We then investigated the usefulness of the cough test by major primary disease. In cerebrovascular disease patients, sensitivity was found to be 0.76, specificity was 0.82, efficiency was 0.79, PPV was 0.73, and NPV was 0.84. In head or neck cancer patients, sensitivity was found to be 1.00, specificity was 0.97, efficiency was 0.98, PPV was 0.93, and NPV was 1.00. In neuromuscular disease patients, sensitivity was found to be 0.83, specificity was 0.84, efficiency was 0.84, PPV was 0.56, and NPV was 0.95. In respiratory disease patients, sensitivity was found to be 0.67, specificity was 0.81, efficiency was 0.76, PPV was 0.67, and NPV was 0.81. In tracheostomy patients, sensitivity was found to be 0.71, specificity was 1.00, efficiency was 0.78, PPV was 1.00, and NPV was 0.50. In dementia patients, sensitivity was found to be 1.00, specificity was 1.00, efficiency was 1.00, PPV was 1.00, and NPV was 1.00. Based on these results, the cough test performed by inhaling citric acid is considered to be a useful tool to screen for SA regardless of disease.
【Purpose】Reclining the body backward to make the bolus pass smoothly from the oral cavity to the pharynx shortens the transit time in patients with oral phase disorder. We investigated how the transit time of bolus through the oral cavity differs by changing the eating posture, food form and feeding therapy with the aims of safer eating and improvement of patients' self-support in eating.
【Subject and methods】Twenty-nine patients were enrolled in this study (16 males and 13 females, average age 73 years). In these patients, video-fluorography (VF) examination was performed using gelatin jelly, rice porridge and thickened water as test foods. Barium sulfate with 30% concentration was used to contrast these test foods. The eating postures were set at 30 to 45 degrees and 60 to 90 degrees from the horizontal. The time between the moment when the bolus reached the middle of the tongue and the moment when the end part of the bolus reached the narrow palate arch was measured as the transit time by viewing VF images.
【Results】The transit time of jelly was 4.6 ± 4.8 seconds, that of rice porridge was 8.3 ± 8.1 seconds, and that of thickened water was 2.2 ± 2.1 seconds at 30 to 45 degrees, while the transit time of jelly was 6.9 ± 7.0 seconds, that of rice porridge was 7.0±6.6 seconds, and that of thickened water was 3.1±2.7 seconds at 60 to 90 degrees. The transit tme of thickened water was shorter than that of gelatin jelly and that of rice porridge for any posture. The transit time of rice porridge was the longest for any posture. The jelly was transferred more quickly at 30 to 45 degrees than at 60 to 90 degrees (p ＜ 0.05).
【Conclusion】We recommend using jelly at the beginning of feeding therapy. It is better to set the eating posture at 30 to 45 degrees to improve patients' safety and reduce their burden. On the other hand, when thickened water and rice porridge is used for rehabilitaion, the transit time did not differ significantly according to eating posture. However, the eating posture of 60 to 90 degrees might enhance the level of patients' daily activity if the patients do not have any serious disorder in the pharyngeal swallowing phase.
【Objective】This study investigated the recovery score and the clinical application after dysphagia rehabilitation for about 9 years in an acute care hospital. In this report we try to make it clear what factors are effective to lead into recovery in an acute care hospital and point future problems.
【Subjects and Methods】The subjects were 491 adult dysphagic inpatients (303 males and 188 females, average age 73.4). We measured their dysphagia severity scale (“DSS”) before and after dysphagia rehabilitation from view point of doctors of otorhinolaryngology and speech-language-hearing therapists, and defined the difference scale between the start and end of training as the recovery score. The recovery score of DSS was analyzed on the attribute of patients, the condition of dysphagia, the diagnosis of dysarthria and the training period etc. We also measured their diet status before and after dysphagia rehabilitation. The recovery score of diet status was examined along relation to the recovery score DSS.
【Results】The results showed that the average recovery score DSS were 1.60, and the level with aspiration reduced to half in 36.0%. Statistics indicated that these were minor factors in the recovery score of DSS that sex, age, tracheotomy tube at the start of training and dysarthria. On the other hand, these were major factors that the cause of disease, the region of brain damaged, diet status at the start of training, the type of aspiration, aspiration pneumonia in patients' medical history, dementia, the recovery score of diet status, the period between the onset and start of training and the training period.
【Discussion】 We needed to prevent aspiration pneumonia, and to choose the nutritional level based the correct assessment of dysphagia for development of effective method of dysphagia rehabilitation in an acute care hospital. It was necessary to consider the training contents according to condition of cure stage. We should provide the necessity period for recovery of dysphagia. In addition, when inpatients changed the hospitals after cure and therapy, we should cooperate with the convalescent hospital for the continuous dysphagia rehabilitation with no gap.
【Purpose】To evaluate the hyoid bone dynamic phase of swallowing in normal subjects by ultrasonography.
【Subject and Methods】Date were obtained from 15 healthy volunteers (mean age：34.9±9.3), and the subjects were divided into three groups：5 subjects in their twenties, 5 in their thirties, and 5 in their forties. The subjects were examined sitting in the upright position, with their back resting against a wall to control movement. With the transducer placed in longitudinal scan above the larynx, the hyoid bone was located in the middle of the screen. The hyoid bone was identified on the scan as a high echoic area with posterior acoustic shadow. The subjects swallowed 5 ml of mineral water and measurements were taken 5 times. The images were analyzed by software (image J), and digital-ultrasonographic recordings were viewed at 30 frames/s for 3 seconds. Frozen frames of the moving image were analyzed, and range of movement of the hyoid bone from the resting point was measured (horizontal migration length, perpendicular migration length).
【Results】In this study, normal hyoid bone trajectory was easily visualized by ultrasonography. In all cases, the trajectory of the hyoid bone identified by ultrasonographic analysis was confirmed to be similar to that by videofluorography. Thus, ultrasonography can accurately determine the swallowing duration and trajectory of hyoid bone movement. Regarding the duration of measurements of 15 normal subjects, significant differences were found between the twenties group or thirties group and forties group (P＜0.05), but differences between the thirties group and forties group were not significant (P＝0.87).
【Conclusion】The results show that the dynamic phase image of the hyoid bone movement can be revealed by ultrasonographic visualization. Ultrasonography can be used for determining the position of the hyoid bone as a new technique for dysphagia, which may be useful in the diagnosis of swallowing disorders.
【Purpose】To report a patient with Parkinson's disease in whom sound rhythm was effective for training in eating/swallowing.
【Patient】A 66-year-old male patient with Parkinson's disease begun with tremor of the upper limb since 1998, who had been diagnosed as having aspiration pneumonia in 2006, was admitted to our hospital for a close examination of aspiration pneumonia and rehabilitation.
【Methods】The training consisted of indirect one (tongue training and Mendelsohn method, as well as neck stretch) and sound rhythm training. Each training period was 1 month with a 2-week withdrawal interval. Qualitative assessment was performed using VF (videofluoroscopic examination of swallowing) to examine aspiration and pharyngeal residue, while quantitative assessment was done based on oral transit duration (OTD) and pharyngeal transit duration (PTD). Diets for the examination were jelly and juice.
【Results】Qualitatively, improvement in pharyngeal residue and aspiration were observed after the sound rhythm training. Quantitatively, OTD was shortened from 3.97±0.54 sec to 0.94±0.08 sec (p＜0.05) when taking jelly, and from 2.76±0.39 sec to 0.94±0.02 sec (p＜0.05) when taking juice.
【Conclusions】Sound rhythm was thought to improve voluntary movement in the oral propulsive phase, which resulted in a stable deglutition movement. Rythm stimulation was effective in a patient with Parkinson's disease for training in swallowing.