Objectives：This study observed the normal pharyngeal swallow in terms of viewing of whiteout，movement of the epiglottis and arytenoids closure，and examined the influence of chewing by using videoendoscopy (VE)．

Subjects and Methods： Seven healthy volunteers participated in this study．The tip of the endoscope was placed at two positions， high position (HIGH) and low position (LOW)，and we monitored dry swallow，command swallow of 5 ml of 50％ liquid barium as well as swallow with chewing，and eating of 8 g of corned beef．Subjects were instructed to carry out each of the swallows 3 times．We observed whiteout，movement of the epiglottis and arytenoids closure． The total numbers of trials were 168 swallows； 4 swallows were deleted technically．

Results： We observed movement of the epiglottis and arytenoids closure before and after whiteout from about 70％ to 90％，although we had to select the tip position (HIGH or LOW)．HIGH was suitable for observing the soft palate and return of the epiglottis．LOW was suitable for indicating the start of movement of the epiglottis and of the arytenoids closure．The manner of observation of movement of the epiglottis was different among the subjects． Chewing did not influence the viewing of the epiglottis movement before whiteout． In the swallow with chewing， there were many trials in which arytenoids had not closed before the start of movement of the epiglottis．

Discussion： VE showed viewing of movement of the epiglottis and arytenoids closure by changing the tip position．The manner of observation of movement of the epiglottis varied among individuals． This suggests that the timings of the movement of epiglottis and soft palate are different in each subject． Chewing did not influence the viewing of swallowing events and showed the delay of arytenoids closure． This suggests that VE will be useful for swallowing research including swallow with chewing， and that a synchronized study with videofluorography might reveal new information about swallowing mechanisms．

When a bolus is formed and maintained during swallowing，the oral cavity and pharynx cavity are interrupted by the contact of the tongue and the palate．Dysphagia is often induced with this interrupting dysfunction．There are many methods of evaluating the tongue surface shape in forming a bolus by two-dimensional measurements，but it is too difficult to evaluate the whole tongue shape．In this paper，standardization using a three-dimensional ultrasound system was researched to clarify the involvement of dysphagia in the defectiveness and/or dysfunction of the tongue and the palate．Characteristic changes of tongue shape in holding water on its surface were examined according to the volume of water bolus．The subjects were six healthy adult males (average age 26.0 years old)．The operation of the ultrasound probe was standardized by using an electronic motor to improve the image accuracy before evaluating the tongue shape．An aluminum marker was stuck on the tongue surface as a reference．A certain volume of water was held in the mouth，and a three-dimensional image of the tongue shape was scanned by the probe from the submandible．Measurement of the tongue and the palate contact was done in three directions (width，rear length，and depth) with the reference marker．It was suggested that the least distortion was achieved for probe settings of rotation radius of 20 cm，rotational speed of 1.6°/s and frequency of 6.0 MHz for tongue imaging．Using 3-D US，the tongue surface shape and its changes could be measured objectively，and most of the objects corresponded to a change in the volume of bolus by three-dimensionally changing the tongue surface shape．This three-dimensional tongue shape observation with forming a bolus is effective for evaluating and diagnosing not only abnormal forms of the tongue but also functional disorders．

We have introduced the diet for dysphagia to the patients undergoing subtotal esophagectomy，and clarified the influence of introduction of diet for dysphagia on the nutritional status of patients．We have compared changes in the nutritional status of the patients at the point of admission and discharge，or before and after the introduction of diet for dysphagia．30 consecutive patients who received subtotal esophagectomy were divided to two groups and both groups included 15 patients．The first group without introduction of diet for dysphagia (10 males and 5 females with the average age of 65.7 ± 10.8) was regarded as the control group，and another group with introduction of diet for dysphagia (12 males and 3 females with the average age of 65.5 ± 8.6) was regarded as the diet for dysphagia group．Both groups were compared by the body weight，body mass index (BMI)，body weight reduction rate，serum albumin，hemoglobin，energy intake adequacy and occurrence of aspiration pneumonia．At the point of discharge， body weight and BMI reduced as compared with those at the time of admission significantly (p＜0.001) on both groups，and there was no significant difference of body weight reduction rate between the control group and the diet for dysphagia group (i.e., 10.4 ± 4.9％ and 7.8 ± 8.6％)．Also，the energy intake adequacy was no significant difference between the control group and the diet for dysphagia group，i．e., 80.9 ± 18.4％ in the control group and 88.2 ± 14.6％ in the diet for dysphagia group．Data of hemoglobin and serum albumin level in the control group at the point of discharge were significant lower (p＜0.001) than the point of admission，however there was no significant difference in the diet for dysphagia group．Also，occurrence of aspiration pneumonia was significantly lower (p＜0.05) in the diet for dysphagia group compared with the control group (i.e., 6.7％ and 40.0％)．From these results，at the point of discharge，the nutritional status of the diet for dysphagia group at the time of discharge should be better than that of the control group，and the introduction of diet for dysphagia showed decreased rate of the occurrence of the aspiration pneumonia．Therefore，it is suggested that the introduction of diet for dysphagia prevents the decline of nutritional status of patients after subtotal esophagectomy．

We examined three ways to help disabled children ingest，as follows：

1） Providing appropriate foods with good texture，softness and of the right size to be fed for their development of ingestion

2） Using bottles for a long period of time

3） Providing a period of encouraging to eat without assistance

The following results were obtained．

a）Some children eat foods that are more difficult to ingest．After changing the foods to ones that are easier to ingest and suggesting ways of assistance and appropriate eating posture，the way of eating was improved．

b） Using bottles for a long period of time impeded their development of ingestion due to remaining tongue thrust，infantile swallowing and failure to close the mouth．After becoming able to capture foods by closing the mouth， it is very important to use a spoon to take in milk or other liquid，and not to suck from the bottle，for the development of ingestion．

c） Some children may develop oral movement for chewing．If we allow them to eat without assistance too early，they tend to lose the ability of managing food with hand and mouth coordination and fail to chew properly．

Cooperation among parents，teachers and training staff is very important in order to improve disabled children's eating ability．A multi-disciplinary approach is a synergistic approach to help disabled children with dysphagia， and the approach should be continued through their school years．

The importance and effectiveness of a multi-disciplinary approach for handicapped children when giving training for ingestion is well-known， but some cases present great difficulties for such training．In this study，we examined children who cannot swallow or had refused to eat orally for more than a year．In 12 years，716 cases had visited our clinic for ingestion，of which 24 had swallowing difficulties and needed tube feeding absolutely (Group 1)，while 21 cases seemed to have no severe anatomical or motor problems of swallowing and managing food in their oral cavities (Group 2)．We divided Group 2 into three sub-groups．The first group had a history of surgery or treatment on their face， oral cavity or esophagus． The second group was the so-called Costello syndrome． The third group had a history of treatment for uncontrollable epilepsy with severe mental retardation． The first group had large differences among their prognosis of eating．There was a period before and after surgery when eating was inhibited．The prognosis seemed to depend on their period for which eating was inhibited．There seemed to be a critical period of eating．Their appetite of eating orally will not develop if they pass the duration being tube-fed without experiencing tasting．Costello syndrome is characterized by natural development of appetite to eat orally during school age．We did not find the reason why some cases of uncontrollable epilepsy with severe mental retardation refused to eat，but speculated that they had poor ability to adapt to even small environmental changes．