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Park FS, Nahmias J, Schubl S, Swentek L, Guner Y, Goodman LF, Emigh B, Grigorian A. Adolescent Trauma Patients With Isolated Head Trauma and Glasgow Coma Scale 6-8: Routine Intubation? Am Surg 2024; 90:882-886. [PMID: 37982759 DOI: 10.1177/00031348231212583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
BACKGROUND Recent evidence suggests that routine intubation upon arrival for adults with isolated head trauma and a depressed Glasgow Coma Scale (GCS) score is associated with increased risk of morbidity and mortality. Whether these outcomes are similar within an adolescent trauma population has not been previously investigated. We hypothesized intubation upon arrival for adolescent trauma patients with isolated head trauma to be associated with a higher risk of death and prolonged length of stay (LOS). METHODS The 2017-2019 TQIP was queried for adolescents (age 12-16) presenting after isolated blunt head trauma (abbreviated injury scale [AIS] <1 spine/chest/abdomen/upper-extremity/lower-extremity) and GCS 6-8 on arrival. Transferred patients, dead-on-arrival, and those undergoing emergent operation from the emergency department were excluded. Patients intubated within one-hour were compared to patients not intubated within one-hour. A multivariable logistic regression analysis was performed adjusting for age, sex, GCS, and AIS-grade for the head. RESULTS From 141 patients, 73 (51.8%) were intubated upon arrival. Intubated patients had a low complication rate (5.6%). Intubated and non-intubated patients had a similar rate and mortality risk (6.8% vs 1.5%, P = .11) (OR 1.84, CI .08-43.69, P = .71) and median length of stay (LOS) (2 days vs 2 days, P = .13). DISCUSSION Unlike adult patients, adolescents with isolated head trauma and a depressed GCS have similar outcomes if they are intubated upon arrival. Utilizing initial GCS score to determine which adolescent trauma patients with isolated head trauma should be intubated appears to be a safe practice.
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Affiliation(s)
- Flora S Park
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine School of Medicine, Orange, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine School of Medicine, Orange, CA, USA
| | - Sebastian Schubl
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine School of Medicine, Orange, CA, USA
| | - Lourdes Swentek
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine School of Medicine, Orange, CA, USA
| | - Yigit Guner
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine School of Medicine, Orange, CA, USA
- Department of Surgery, Division of Pediatric Surgery, Children's Health Orange County, Orange, CA, USA
| | - Laura F Goodman
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine School of Medicine, Orange, CA, USA
- Department of Surgery, Division of Pediatric Surgery, Children's Health Orange County, Orange, CA, USA
| | - Brent Emigh
- Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Areg Grigorian
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine School of Medicine, Orange, CA, USA
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2
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Troll C, Trapl-Grundschober M, Teuschl Y, Cerrito A, Compte MG, Siegemund M. A bedside swallowing screen for the identification of post-extubation dysphagia on the intensive care unit - validation of the Gugging Swallowing Screen (GUSS)-ICU. BMC Anesthesiol 2023; 23:122. [PMID: 37055724 PMCID: PMC10099025 DOI: 10.1186/s12871-023-02072-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/29/2023] [Indexed: 04/15/2023] Open
Abstract
PURPOSE Screening for dysphagia at the intensive care unit (ICU) soon after extubation can prevent aspiration, pneumonia, lower mortality, and shorten re-feeding interval. This study aimed to modify the Gugging Swallowing Screen (GUSS), which was developed for acute stroke patients, and to validate it for extubated patients in the ICU. METHODS In this prospective study, forty-five patients who had been intubated for at least 24 h were recruited consecutively at the earliest 24 h after extubation. The modified GUSS-ICU was performed twice by two speech and language therapists independently. Concurrently, gold standard the flexible endoscopic evaluation of swallowing (FEES) was performed by an otorhinolaryngologist. Measurements were conducted within a three-hour period; all testers were blinded to each other's results. RESULTS According to FEES, 36 of 45 (80%) participants were diagnosed with dysphagia; 13 of those were severe, 12 moderate, and 11 mild. Compared to FEES, the GUSS-ICU predicted dysphagia well (area under the curve for the initial rater pair: 0.923, 95% CI 0.832-1.000 and 0.923, 95% CI 0.836 -1.000 for the second rater pair). The sensitivity was 91.7% (95% CI 77.5-98.3%) and 94.4% (95% CI 81.3-99.3%); the specificity was 88.9% (51.8-99.7%) and 66.7% (29.9-92.5%); the positive predictive values were 97.1% (83.8-99.5%) and 91.9% (81.7-96.6%), and the negative predictive values were 72.7% (46.8-89%) and 75% (41.9-92.6%) for the first and second rater pairs, respectively. Dysphagia severity classification according to FEES and GUSS-ICU correlated strongly (Spearman's rho: 0.61 for rater 1 and 0.60 for rater 2, p < 0.001). Agreement by all testers was good (Krippendorffs Alpha: 0.73). The interrater reliability showed good agreement (Cohen`s Kappa: 0.84, p < 0.001). CONCLUSION The GUSS-ICU is a simple, reliable, and valid multi-consistency bedside swallowing screen to identify post-extubation dysphagia at the ICU. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04532398,31/08/2020.
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Affiliation(s)
- Claudia Troll
- Department of Therapies, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | | | - Yvonne Teuschl
- Department for Clinical Neurosciences and Preventive Medicine, University for Continuing Education Krems, Dr.-Karl-Dorrek-Strasse 30, 3500, Krems, Austria
| | - Adrien Cerrito
- Bern University of Applied Sciences Health, Department of Health Professions, Murtenstrasse 10, 3008, Bern, Switzerland
| | | | - Martin Siegemund
- Intensive Care Unit, Department Acute Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
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3
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Heidler MD. [Dysphagia in Tracheostomized Patients after Long-Term Mechanical Ventilation - Become Sensitive to Reduced Pharyngo-Laryngeal Sensitivity]. Laryngorhinootologie 2023; 102:27-31. [PMID: 36580929 DOI: 10.1055/a-1076-9686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Independent of the type of critical illness, tracheostomized patients have a high risk of developing a dysphagia. This is potentially life-threatening as it can lead to aspiration and pneumonia. It is therefore essential to perform swallowing diagnostics by means of a bolus dyeing test and/or FEES before oral feeding. Since a physiological airflow through the larynx and adequate subglottic pressure are key components of an effective swallowing act, oralisation should be avoided as far as possible with a blocked tracheal cannula.
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Affiliation(s)
- M-D Heidler
- Neurologisches Rehabilitationszentrum (N1), Brandenburg-Klinik, Bernau
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4
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Qian J, Min X, Wang F, Xu Y, Fang W. Paroxysmal Sympathetic Hyperactivity in Adult Patients with Brain Injury: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 166:212-219. [PMID: 35398326 DOI: 10.1016/j.wneu.2022.03.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Paroxysmal sympathetic hyperactivity (PSH) is a syndrome of excessive sympathetic activity, mainly occurring in severe traumatic brain injury. However, few studies have reported the frequency of PSH and its related risk factors in adult patients with brain injury. METHODS We performed this systematic review and meta-analysis to estimate the combined incidence of PSH and the associated risk factors in adult patients with brain injury. This study was registered with the PROSPERO international prospective register of systematic reviews (https://www.crd.york. ac.uk/PROSPERO/Identifier: CRD 42021260493), and a systematic search was conducted of the scientific databases Embase, PubMed, Web of Science, Cochrane Library, and Google Scholar. All identified observational studies regarding the incidence and risk factors of PSH in adult patients with brain injury were included. Two authors extracted data independently; data were analyzed by STATA version 16. RESULTS The search yielded 9 studies involving 1643 adult patients. PSH was detected in 438 patients. The combined incidence of PSH in adult patients with brain injury was 27.4% (95% confidence interval [CI], 0.190-0.358). The risk factors include patients' age (SMD = -0.592; I2 = 77.5%; 95% CI, -1.027 to -0.156; P = 0.008), traffic accident (odds ratio [OR], 1.783; I2 =18.0%; 95% CI, 1.128-2.820; P = 0.013), admission Glasgow Coma Scale score (SMD = -1.097; I2 =28.3%; 95% CI, -1.500 to -0.693; P = 0.000), hydrocephalus (OR, 3.936; I2 =67.9%; 95% CI, 1.144-13.540; P = 0.030), and diffuse axonal injury (OR, 4.747; I2 =71.1%; 95% CI, 1.221-18.463; P = 0.025) and were significantly associated with the presence of PSH after brain injury. CONCLUSIONS PSH occurs in nearly a quarter of adult patients with brain injury. Patient's age, traffic accident, admission Glasgow Coma Scale score, hydrocephalus, and diffuse axonal injury were risk factors for PSH in adult patients with brain injury. These findings may contribute to novel strategies for early diagnosis and interventions that aid in the rehabilitation of patients with brain injury.
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Affiliation(s)
- Jiawei Qian
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoqiang Min
- College of Pharmaceutical Science, Zhejiang University of Technology, Hangzhou, China
| | - Feng Wang
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuanhua Xu
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wenchao Fang
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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5
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Kumar RG, Zhong X, Whiteneck GG, Mazumdar M, Hammond FM, Egorova N, Lercher K, Dams-O'Connor K. Development and Validation of a Functionally Relevant Comorbid Health Index in Adults Admitted to Inpatient Rehabilitation for Traumatic Brain Injury. J Neurotrauma 2022; 39:67-75. [PMID: 34779252 PMCID: PMC8917887 DOI: 10.1089/neu.2021.0180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Several studies have characterized comorbidities among individuals with traumatic brain injury (TBI); however, there are few validated TBI comorbidity indices. Widely used indices (e.g., Elixhauser Comorbidity Index [ECI]) were developed in other patient populations and anchor to mortality or healthcare utilization, not functioning, and notably exclude conditions known to co-occur with TBI. The objectives of this study were to develop and validate a functionally relevant TBI comorbidity index (Fx-TBI-CI) and to compare prognostication of the Fx-TBI-CI with the ECI. We used data from the eRehabData database to divide the sample randomly into a training sample (N = 21,292) and an internal validation sample (N = 9166). We used data from the TBI Model Systems National Database as an external validation sample (N = 1925). We used least absolute shrinkage and selection operator (LASSO) regression to narrow the list of functionally relevant conditions from 39 to 12. In internal validation, the Fx-TBI-CI explained 14.1% incremental variance over an age and sex model predicting the Functional Independence Measure (FIM) Motor subscale at inpatient rehabilitation discharge, compared with 2.4% explained by the ECI. In external validation, the Fx-TBI-CI explained 4.9% incremental variance over age and sex and 3.8% over age, sex, and Glasgow Coma Scale score,compared with 2.1% and 1.6% incremental variance, respectively, explained by the ECI. An unweighted Sum Condition Score including the same conditions as the Fx-TBI-CI conferred similar prognostication. Although the Fx-TBI-CI had only modest incremental variance over demographics and injury severity in predicting functioning in external validation, the Fx-TBI-CI outperformed the ECI in predicting post-TBI function.
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Affiliation(s)
- Raj G. Kumar
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Xiaobo Zhong
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, New York, USA.,Department of Population Health Science and Policy, and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, New York, USA.,Department of Population Health Science and Policy, and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Flora M. Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
| | - Natalia Egorova
- Department of Population Health Science and Policy, and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kirk Lercher
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kristen Dams-O'Connor
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Address correspondence to: Kristen Dams-O'Connor, PhD, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1163, New York, NY 10029, USA kristen.dams-o'
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6
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Wirth R, Dziewas R. [Dysphagia - from Pathophysiology to Treatment]. Laryngorhinootologie 2021; 101:62-73. [PMID: 34963157 DOI: 10.1055/a-1477-6117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
More than 5 million persons in Germany suffer from swallowing disorders (dysphagia), predominantly oropharyngeal dysphagia. Due to the demographic changes in our population, the prevalence rates are expected to increase. Multiple conditions may be the cause of dysphagia and dysphagia may lead to various symptoms. Esophageal dysphagia is predominantly accompanied by regurgitation, vomiting, pain and foreign body sensation in the esophageal region. Oropharyngeal dysphagia is characterized by cough, hawking and airway disease. In some patients with oropharyngeal dysphagia, symptoms may be completely absent or are not attributed to dysphagia. Both forms of dysphagia are regularly accompanied by difficulties with nutritional intake and consecutive malnutrition. Therefore, the diagnostic and therapy of dysphagia should always be accompanied by nutritional support.
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7
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Chang MC, Kwak S. Videofluoroscopic Swallowing Study Findings Associated With Subsequent Pneumonia in Patients With Dysphagia Due to Frailty. Front Med (Lausanne) 2021; 8:690968. [PMID: 34291064 PMCID: PMC8287055 DOI: 10.3389/fmed.2021.690968] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/14/2021] [Indexed: 11/13/2022] Open
Abstract
Dysphagia in frailty or deconditioning without specific diagnosis that may cause dysphagia such as stroke, traumatic brain injury, or laryngeal pathology, has been reported in previous studies; however, little is known about which findings of the videofluoroscopic swallowing study (VFSS) are associated with subsequent pneumonia and how many patients actually develop subsequent pneumonia in this population. In this study, we followed 190 patients with dysphagia due to frailty or deconditioning without specific diagnosis that may cause dysphagia for 3 months after VFSS and analyzed VFSS findings for the risk of developing pneumonia. During the study period, the incidence of subsequent pneumonia was 24.74%; regarding the VFSS findings, (1) airway penetration (PAS 3) and aspiration (PAS 7 and 8) were associated with increased risk of developing pneumonia, and (2) the functional dysphagia scale (FDS) scores of the patients who developed subsequent pneumonia were higher than those of the patients who did not develop subsequent pneumonia. Our study findings might assist clinicians in making clinical decisions based on the VFSS findings in this population.
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Affiliation(s)
- Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, South Korea
| | - Soyoung Kwak
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, South Korea
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8
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Dziewas R, Allescher HD, Aroyo I, Bartolome G, Beilenhoff U, Bohlender J, Breitbach-Snowdon H, Fheodoroff K, Glahn J, Heppner HJ, Hörmann K, Ledl C, Lücking C, Pokieser P, Schefold JC, Schröter-Morasch H, Schweikert K, Sparing R, Trapl-Grundschober M, Wallesch C, Warnecke T, Werner CJ, Weßling J, Wirth R, Pflug C. Diagnosis and treatment of neurogenic dysphagia - S1 guideline of the German Society of Neurology. Neurol Res Pract 2021; 3:23. [PMID: 33941289 PMCID: PMC8094546 DOI: 10.1186/s42466-021-00122-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
Introduction Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies. Recommendations This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with. Conclusions The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf).
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Affiliation(s)
- Rainer Dziewas
- Klinik für Neurologie, Universitätsklinik Münster, 48149 Münster, Germany. .,Klinik für Neurologie und Neurologische Frührehabilitation, Klinikum Osnabrück, Am Finkenhügel 1, 49076, Osnabrück, Germany.
| | - Hans-Dieter Allescher
- Zentrum für Innere Medizin, Klinikum Garmisch-Partenkirchen GmbH, Auenstraße 6, 82467, Garmisch-Partenkirchen, Germany
| | - Ilia Aroyo
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Grafenstr. 9, 64283, Darmstadt, Germany
| | | | | | - Jörg Bohlender
- Universitätsspital Zürich, ORL-Klinik, Abteilung für Phoniatrie und Klinische Logopädie, Frauenklinikstr. 24, 8091, Zürich, Schweiz
| | - Helga Breitbach-Snowdon
- Schule für Logopädie, Universitätsklinikum Münster, Kardinal-von-Galen-Ring 10, 48149, Münster, Germany
| | | | - Jörg Glahn
- Universitätsklinik für Neurologie und Neurogeriatrie, Johannes Wesling Klinikum Minden, Hans-Nolte Strasse 1, 32429, Minden, Germany
| | - Hans-Jürgen Heppner
- Private Universität Witten/Herdecke gGmbH, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany
| | - Karl Hörmann
- University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christian Ledl
- Abteilung Sprach-, Sprech- und Schlucktherapie, Schön Klinik Bad Aibling SE & Co. KG, Kolbermoorer Str. 72, 83043, Bad Aibling, Germany
| | - Christoph Lücking
- Schön Klinik München Schwabing, Parzivalplatz 4, 80804, München, Germany
| | - Peter Pokieser
- Medizinische Universität Wien, Teaching Center / Unified Patient Program, AKH Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Joerg C Schefold
- Universitätsklinik für Intensivmedizin, Inselspital, Universitätsspital Bern, 3010, Bern, Schweiz
| | | | - Kathi Schweikert
- REHAB Basel, Klinik für Neurorehabilitation und Paraplegiologie, Im Burgfelderhof 40, 4012, Basel, Schweiz
| | - Roland Sparing
- VAMED Klinik Hattingen GmbH, Rehabilitationszentrum für Neurologie, Neurochirurgie, Neuropädiatrie, Am Hagen 20, 45527, Hattingen, Germany
| | - Michaela Trapl-Grundschober
- Klinische Abteilung für Neurologie, Therapeutischer Dienst, Universitätsklinikum Tulln, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Alter Ziegelweg 10, 3430, Tulln an der Donau, Österreich
| | - Claus Wallesch
- BDH-Klinik Elzach gGmbH, Am Tannwald 1, 79215, Elzach, Germany
| | - Tobias Warnecke
- Klinik für Neurologie, Universitätsklinik Münster, 48149 Münster, Germany
| | - Cornelius J Werner
- Sektion Interdisziplinäre Geriatrie, Klinik für Neurologie, Medizinische Fakultät, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Johannes Weßling
- Zentrum für Radiologie, Neuroradiologie und Nuklearmedizin, Clemenskrankenhaus Münster, Düesbergweg 124, 48153, Münster, Germany
| | - Rainer Wirth
- Klinik für Altersmedizin und Frührehabilitation, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Katholische Kliniken Rhein-Ruhr, Hölkeskampring 40, 44625, Herne, Germany
| | - Christina Pflug
- Klinik und Poliklinik für Hör-, Stimm- und Sprachheilkunde, Universitäres Dysphagiezentrum Hamburg, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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9
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Rückert J, Lenz P, Heinzow H, Wessling J, Warnecke T, Herrmann IF, Strahl M, Lenze F, Nowacki T, Domagk D. Functional endoscopy in neurogenic dysphagia: a feasibility study focusing on the esophageal phase of swallowing. Endosc Int Open 2021; 9:E646-E652. [PMID: 33880400 PMCID: PMC8050561 DOI: 10.1055/a-1380-3224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/30/2020] [Indexed: 11/01/2022] Open
Abstract
Background and study aims Due to demographic transition, neurogenic dysphagia has become an increasingly recognized problem. Patients suffering from dysphagia often get caught between different clinical disciplines. In this study, we implemented a defined examination protocol for evaluating the whole swallowing process by functional endoscopy. Special focus was put on the esophageal phase of swallowing. Patients and methods This prospective observational multidisciplinary study evaluated 31 consecutive patients with suspected neurogenic dysphagia by transnasal access applying an ultrathin video endoscope. Thirty-one patients with gastroesophageal reflux symptoms were used as a control group. We applied a modified approach including standardized endoscopic positions to compare our findings with fiberoptic endoscopic evaluation of swallowing and high-resolution manometry. The primary outcome measure was feasibility of functional endoscopy. Secondary outcome measures were adverse events (AEs), tolerability, and pathologic endoscopic findings. Results Functional endoscopy was successfully performed in all patients. No AEs were recorded. A variety of disorders were documented by functional endoscopy: incomplete or delayed closure of the upper esophageal sphincter in retroflex view, clearance disturbance of tubular esophagus, esophageal hyperperistalsis, and hypomotility. Analysis of results obtained with the diagnostic tools showed some discrepancies. Conclusions By interdisciplinary cooperation with additional assessment of the esophageal phase of deglutition using the innovative method of functional endoscopy, the diagnosis of neurogenic disorders including dysphagia may be significantly improved, leading to a better clinical understanding of complex dysfunctional patterns. To the best of our knowledge, this is the first study to show that a retroflex view of the ultrathin video endoscope within the esophagus can be safely performed. [NCT01995929].
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Affiliation(s)
- Jan Rückert
- Department of Medicine I, Josephs-Hospital Warendorf, Academic Teaching Hospital, University of Muenster, Warendorf, Germany
| | - Philipp Lenz
- Department of Medicine B, University of Muenster, Muenster, Germany,Department of Palliative Medicine, University of Muenster, Muenster, Germany
| | - Hauke Heinzow
- Department of Medicine B, University of Muenster, Muenster, Germany
| | - Johannes Wessling
- Department of Clinical Radiology, University of Muenster, Muenster, Germany,Department of Radiology, Clemens Hospital Muenster, Muenster, Germany
| | - Tobias Warnecke
- Department of Neurology, University of Muenster, Muenster, Germany
| | | | | | - Frank Lenze
- Department of Medicine I, Josephs-Hospital Warendorf, Academic Teaching Hospital, University of Muenster, Warendorf, Germany
| | - Tobias Nowacki
- Department of Medicine I, Josephs-Hospital Warendorf, Academic Teaching Hospital, University of Muenster, Warendorf, Germany,Department of Medicine B, University of Muenster, Muenster, Germany
| | - Dirk Domagk
- Department of Medicine I, Josephs-Hospital Warendorf, Academic Teaching Hospital, University of Muenster, Warendorf, Germany,Department of Medicine B, University of Muenster, Muenster, Germany
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10
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Blanke EN, Holmes GM, Besecker EM. Altered physiology of gastrointestinal vagal afferents following neurotrauma. Neural Regen Res 2021; 16:254-263. [PMID: 32859772 PMCID: PMC7896240 DOI: 10.4103/1673-5374.290883] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The adaptability of the central nervous system has been revealed in several model systems. Of particular interest to central nervous system-injured individuals is the ability for neural components to be modified for regain of function. In both types of neurotrauma, traumatic brain injury and spinal cord injury, the primary parasympathetic control to the gastrointestinal tract, the vagus nerve, remains anatomically intact. However, individuals with traumatic brain injury or spinal cord injury are highly susceptible to gastrointestinal dysfunctions. Such gastrointestinal dysfunctions attribute to higher morbidity and mortality following traumatic brain injury and spinal cord injury. While the vagal efferent output remains capable of eliciting motor responses following injury, evidence suggests impairment of the vagal afferents. Since sensory input drives motor output, this review will discuss the normal and altered anatomy and physiology of the gastrointestinal vagal afferents to better understand the contributions of vagal afferent plasticity following neurotrauma.
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Affiliation(s)
- Emily N Blanke
- Department of Neural and Behavioral Sciences, Penn State University College of Medicine, Hershey, PA, USA
| | - Gregory M Holmes
- Department of Neural and Behavioral Sciences, Penn State University College of Medicine, Hershey, PA, USA
| | - Emily M Besecker
- Department of Health Sciences, Gettysburg College, Gettysburg, PA, USA
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Jakobsen D, Poulsen I, Schultheiss C, Riberholt C, Curtis D, Petersen T, Seidl R. The effect of intensified nonverbal facilitation of swallowing on dysphagia after severe acquired brain injury: A randomised controlled pilot study. NeuroRehabilitation 2019; 45:525-536. [PMID: 31868691 PMCID: PMC7029366 DOI: 10.3233/nre-192901] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is little high-level evidence for the effect of the nonverbal facilitation of swallowing on swallowing ability in the subacute stage of rehabilitation following severe acquired brain injury (ABI). OBJECTIVE To pilot test a randomised controlled trial to determine the effect of an intensification of the nonverbal facilitation of swallowing on dysphagia. METHODS Ten patients with severe ABI and dysphagia were randomised into two groups at a highly specialised neurorehabilitation clinic.The intervention group received an intensification of the nonverbal facilitation of swallowing and the control group received basic care of the face and mouth in addition to treatment as usual for two sessions of 20 minutes per day for three weeks.Outcomes were Functional Oral Intake Scale (FOIS), Penetration Aspiration Scale (PAS), and electrophysiological swallowing specific parameters (EMBI). RESULTS The intensified intervention was feasible. PAS and FOIS scores improved in both groups, with no differences between groups. The swallowing specific parameters reflected clinically observed changes in swallowing. CONCLUSIONS PAS and FOIS are feasible instruments to measure dysphagia. It is possible and valid to measure swallowing frequency and kinematics using electromyography and bioimpedance. The definitive study should have widened inclusion criteria and optimise intervention timing to maintain patient arousal.
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Affiliation(s)
- D. Jakobsen
- Department of Neurorehabilitation, Rigshospitalet, TBI Unit, Copenhagen, Denmark
| | - I. Poulsen
- Department of Neurorehabilitation, Rigshospitalet, TBI Unit, Copenhagen, Denmark
- Department of Science in Nursing Health, Aarhus University, Aarhus, Denmark
| | | | - C.G. Riberholt
- Department of Neurorehabilitation, Rigshospitalet, TBI Unit, Copenhagen, Denmark
| | - D.J. Curtis
- Department of Neurorehabilitation, Rigshospitalet, TBI Unit, Copenhagen, Denmark
| | - T.H. Petersen
- Department of Neurorehabilitation, Rigshospitalet, TBI Unit, Copenhagen, Denmark
| | - R.O. Seidl
- Department of Otolaryngology at UKB, Hospital of the University of Berlin, Charite Medical School, Berlin, Germany
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Dziewas R, Auf dem Brinke M, Birkmann U, Bräuer G, Busch K, Cerra F, Damm-Lunau R, Dunkel J, Fellgiebel A, Garms E, Glahn J, Hagen S, Held S, Helfer C, Hiller M, Horn-Schenk C, Kley C, Lange N, Lapa S, Ledl C, Lindner-Pfleghar B, Mertl-Rötzer M, Müller M, Neugebauer H, Özsucu D, Ohms M, Perniß M, Pfeilschifter W, Plass T, Roth C, Roukens R, Schmidt-Wilcke T, Schumann B, Schwarze J, Schweikert K, Stege H, Theuerkauf D, Thomas RS, Vahle U, Voigt N, Weber H, Werner CJ, Wirth R, Wittich I, Woldag H, Warnecke T. Safety and clinical impact of FEES - results of the FEES-registry. Neurol Res Pract 2019; 1:16. [PMID: 33324882 PMCID: PMC7650078 DOI: 10.1186/s42466-019-0021-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 01/10/2019] [Indexed: 11/10/2022] Open
Abstract
Background At present, the flexible endoscopic evaluation of swallowing (FEES) is one of the most commonly used methods for the objective assessment of swallowing. This multicenter trial prospectively collected data on the safety of FEES and also assessed the impact of this procedure on clinical dysphagia management. Methods Patients were recruited in 23 hospitals in Germany and Switzerland from September 2014 to May 2017. Patient characteristics, professional affiliation of the FEES examiners (physicians or speech and language therapists), side-effects and cardiorespiratory parameters, severity of dysphagia and clinical consequences of FEES were documented. Results 2401 patients, mean age 69.8 (14.6) years, 42.3% women, were included in the FEES-registry. The most common main diagnosis was stroke (61%), followed by Parkinson’s disease (6.5%). FEES was well tolerated by patients. Complications were reported in 2% of examinations, were all self-limited and resolved without sequelae and showed no correlation to the endoscopist’s previous experience. In more than 50% of investigations FEES led to changes of feeding strategies, in the majority of cases an upgrade of oral diet was possible. Discussion This study confirmed that FEES, even when performed by less experienced clinicians is a safe and well tolerated procedure and significantly impacts on the patients’ clinical course. Implementation of a FEES-service in different clinical settings may improve dysphagia care. Trial registration ClinicalTrials.gov NCT03037762, registered January 31st 2017.
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Affiliation(s)
- Rainer Dziewas
- Klinik für Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1A, 48149 Münster, Germany
| | | | - Ulrich Birkmann
- GFO Kliniken Troisdorf, Betriebsstätte St. Johannes Sieglar, Wilhelm-Busch-Str. 9, 53844 Troisdorf, Germany
| | - Götz Bräuer
- Helios Klinikum Aue, Gartenstr. 6, 08280 Aue, Germany
| | - Kolja Busch
- Klinikum Westmünsterland St.Marien-Hospital GmbH, Am Boltenhof 7, 46325 Borken, Germany
| | - Franziska Cerra
- Universitätsklinik für Neurologie und Neurogeriatrie, Johannes Wesling Klinkum, Universitätsklinikum der Ruhr-Universität Bochum, Hans-Nolte-Straße 1, 32429 Minden, Germany
| | - Renate Damm-Lunau
- August-Bier-Klinik, Diekseepromenade 7-11, 23714 Bad Malente-Gremsmühlen, Germany
| | - Juliane Dunkel
- Klinik für Neurologie, Klinikum Kassel, Mönchebergstraße 41-43, 34125 Kassel, Germany
| | - Amelie Fellgiebel
- August-Bier-Klinik, Diekseepromenade 7-11, 23714 Bad Malente-Gremsmühlen, Germany
| | - Elisabeth Garms
- Neurologische Klinik Westend, Michael Wicker GmbH & Co.OHG, Dr.-Born-Straße 9, 34537 Bad Wildungen, Germany
| | - Jörg Glahn
- Universitätsklinik für Neurologie und Neurogeriatrie, Johannes Wesling Klinkum, Universitätsklinikum der Ruhr-Universität Bochum, Hans-Nolte-Straße 1, 32429 Minden, Germany
| | - Sandra Hagen
- Asklepios Kliniken Schildautal, Karl-Herold-Str. 1, 38723 Seesen, Germany
| | - Sophie Held
- Benedictus Krankenhaus Feldafing GmbH & Co. KG, Dr.-Appelhans-Weg 6, 82340 Feldafing, Germany
| | - Christine Helfer
- Klinik für Hals-, Nasen-, Ohrenheilkunde, Kopf- und Halschirurgie und Klinik für Neurologie, Vivantes Klinikum Neukölln, Rudower Str.48, 12351 Berlin, Germany
| | - Mirko Hiller
- Das Dysphagiezentrum, Dysphagienetzwerk Südsachsen, Scherbank 18, 09456 Annaberg Buchholz, Germany
| | - Christina Horn-Schenk
- Klinik für Geriatrie, Marienkrankenhaus Schwerte, Schützenstr. 9, 58239 Schwerte, Germany
| | - Christoph Kley
- GFO Kliniken Troisdorf, Betriebsstätte St. Johannes Sieglar, Wilhelm-Busch-Str. 9, 53844 Troisdorf, Germany
| | - Nikolaus Lange
- Sozialstiftung Bamberg, Buger Straße 80, 96049 Bamberg, Germany
| | - Sriramya Lapa
- Klinik für Neurologie, Klinikum der Goethe-Universität, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| | - Christian Ledl
- Schön Klinik Bad Aibling, Kolbermoorer Str. 72, 83043 Bad Aibling, Germany
| | - Beate Lindner-Pfleghar
- RKU, Universitäts- und Rehabilitationskliniken Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | | | - Madeleine Müller
- REHAB Basel, Klinik für Neurorehabilitation und Paraplegiologie, Im Burgfelderhof 40, 4012 Basel, Switzerland
| | - Hermann Neugebauer
- RKU, Universitäts- und Rehabilitationskliniken Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Duygu Özsucu
- Klinik für Hals-, Nasen-, Ohrenheilkunde, Kopf- und Halschirurgie und Klinik für Neurologie, Vivantes Klinikum Neukölln, Rudower Str.48, 12351 Berlin, Germany
| | - Michael Ohms
- Klinik für Neurologie mit klinischer Neurophysiologie, Herz-Jesu-Krankenhaus Hiltrup, Westfalenstr. 109, 48165 Münster, Germany
| | - Markus Perniß
- OGD Ostprignitz-Ruppiner-Gesundheitsdienste GmbH, Fehrbelliner Str. 38, 16816 Neuruppin, Germany
| | - Waltraud Pfeilschifter
- Klinik für Neurologie, Klinikum der Goethe-Universität, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| | - Tanja Plass
- Neurologische Klinik Westend, Michael Wicker GmbH & Co.OHG, Dr.-Born-Straße 9, 34537 Bad Wildungen, Germany
| | - Christian Roth
- Klinik für Neurologie, Klinikum Kassel, Mönchebergstraße 41-43, 34125 Kassel, Germany
| | - Robin Roukens
- St. Mauritius Therapieklinik Meerbusch, Strümper Straße 111, 40670 Meerbusch, Germany
| | - Tobias Schmidt-Wilcke
- Mauritius Therapieklinik Meerbusch, Strümper Straße 111, 40670 Meerbusch, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Beate Schumann
- Klinik für Neurologie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Julia Schwarze
- Klinik für Neurologie mit klinischer Neurophysiologie, Herz-Jesu-Krankenhaus Hiltrup, Westfalenstr. 109, 48165 Münster, Germany
| | - Kathi Schweikert
- REHAB Basel, Klinik für Neurorehabilitation und Paraplegiologie, Im Burgfelderhof 40, 4012 Basel, Switzerland
| | - Holger Stege
- Klinik für Geriatrie, Ruppiner Kliniken GmbH, Fehrbelliner Straße 38, 16816 Neuruppin, Germany
| | - Dirk Theuerkauf
- Asklepios Fachklinik Fürstenhof, Brunnenallee 39, 34537 Bad Wildungen, Germany
| | - Randall S Thomas
- Asklepios Kliniken Schildautal, Karl-Herold-Str. 1, 38723 Seesen, Germany
| | - Ulrich Vahle
- Klinik für Geriatrie, Marienkrankenhaus Schwerte, Schützenstr. 9, 58239 Schwerte, Germany
| | - Nancy Voigt
- Neurologisches Rehabilitationszentrum Leipzig, 04828 Bennewitz, Muldentalweg 1, Germany
| | - Hermann Weber
- Sozialstiftung Bamberg, Buger Straße 80, 96049 Bamberg, Germany
| | - Cornelius J Werner
- Sektion Interdisziplinäre Geriatrie, Klinik für Neurologie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Rainer Wirth
- Klinik für Altersmedizin und Frührehabilitation, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Katholische Kliniken Rhein-Ruhr, Hölkeskampring 40, 44625 Herne, Germany
| | - Ingo Wittich
- Benedictus Krankenhaus Feldafing GmbH & Co. KG, Dr.-Appelhans-Weg 6, 82340 Feldafing, Germany
| | - Hartwig Woldag
- Klinik für Geriatrie, Ruppiner Kliniken GmbH, Fehrbelliner Straße 38, 16816 Neuruppin, Germany
| | - Tobias Warnecke
- Klinik für Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1A, 48149 Münster, Germany
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Saito Y, Takeuchi H, Fukuda K, Suda K, Nakamura R, Wada N, Kawakubo H, Kitagawa Y. Size of recurrent laryngeal nerve as a new risk factor for postoperative vocal cord paralysis. Dis Esophagus 2018; 31:4986869. [PMID: 29701761 DOI: 10.1093/dote/dox162] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Recurrent laryngeal nerve paralysis (RLNP) is a frequent and serious complication following esophageal cancer surgery. Therefore, this study aims to evaluate the correlation between recurrent laryngeal nerve (RLN) size and RLNP. This was a retrospective study of esophageal cancer patients who underwent thoracoscopic esophagectomy from January 2012 to December 2014. Eighty-four patients were included in the primary analysis. Diameter of the RLN was measured using the digital video recording of surgical procedures by the ratio between scissor and RLN. For evaluation of vocal cord paralysis or paresis, indirect laryngoscopy was performed. Because RLNP more frequently occurs on the left side than the right, we evaluated the correlation between size of the left RLN and left RLNP. The median size of the left RLN was 1.51 mm. We found that the incidence of postoperative left RLNP (Clavien-Dindo classification ≥1) was significantly higher (71% vs. 24%; P < 0.001) in thin RLNs (≤1.5 mm) than in thick RLNs (>1.5 mm). Thin RLN (P < 0.001), female sex (P = 0.025), and being overweight (P = 0.034) were identified as significant independent risk factors for postoperative RLNP. RLNP more easily occurred when the RLN was thin. It is difficult to confirm occurrence of postoperative RLNP before and at extubation. Therefore, it is helpful to know its risk factors including size of RLN.
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Affiliation(s)
- Y Saito
- Department of Surgery, School of Medicine, Keio University, Shinjuku-ku, Tokyo
| | - H Takeuchi
- Department of Surgery, School of Medicine, Keio University, Shinjuku-ku, Tokyo.,Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - K Fukuda
- Department of Surgery, School of Medicine, Keio University, Shinjuku-ku, Tokyo
| | - K Suda
- Department of Surgery, School of Medicine, Keio University, Shinjuku-ku, Tokyo
| | - R Nakamura
- Department of Surgery, School of Medicine, Keio University, Shinjuku-ku, Tokyo
| | - N Wada
- Department of Surgery, School of Medicine, Keio University, Shinjuku-ku, Tokyo
| | - H Kawakubo
- Department of Surgery, School of Medicine, Keio University, Shinjuku-ku, Tokyo
| | - Y Kitagawa
- Department of Surgery, School of Medicine, Keio University, Shinjuku-ku, Tokyo
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[Prolonged weaning during early neurological and neurosurgical rehabilitation : S2k guideline published by the Weaning Committee of the German Neurorehabilitation Society (DGNR)]. DER NERVENARZT 2018; 88:652-674. [PMID: 28484823 DOI: 10.1007/s00115-017-0332-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Prolonged weaning of patients with neurological or neurosurgery disorders is associated with specific characteristics, which are taken into account by the German Society for Neurorehabilitation (DGNR) in its own guideline. The current S2k guideline of the German Society for Pneumology and Respiratory Medicine is referred to explicitly with regard to definitions (e.g., weaning and weaning failure), weaning categories, pathophysiology of weaning failure, and general weaning strategies. In early neurological and neurosurgery rehabilitation, patients with central of respiratory regulation disturbances (e.g., cerebral stem lesions), swallowing disturbances (neurogenic dysphagia), neuromuscular problems (e.g., critical illness polyneuropathy, Guillain-Barre syndrome, paraplegia, Myasthenia gravis) and/or cognitive disturbances (e.g., disturbed consciousness and vigilance disorders, severe communication disorders), whose care during the weaning of ventilation requires, in addition to intensive medical competence, neurological or neurosurgical and neurorehabilitation expertise. In Germany, this competence is present in centers of early neurological and neurosurgery rehabilitation, as a hospital treatment. The guideline is based on a systematic search of guideline databases and MEDLINE. Consensus was established by means of a nominal group process and Delphi procedure moderated by the Association of the Scientific Medical Societies in Germany (AWMF). In the present guideline of the DGNR, the special structural and substantive characteristics of early neurological and neurosurgery rehabilitation and existing studies on weaning in early rehabilitation facilities are examined.Addressees of the guideline are neurologists, neurosurgeons, anesthesiologists, palliative physicians, speech therapists, intensive care staff, ergotherapists, physiotherapists, and neuropsychologists. In addition, this guideline is intended to provide information to specialists for physical medicine and rehabilitation (PMR), pneumologists, internists, respiratory therapists, the German Medical Service of Health Insurance Funds (MDK) and the German Association of Health Insurance Funds (MDS). The main goal of this guideline is to convey the current knowledge on the subject of "Prolonged weaning in early neurological and neurosurgery rehabilitation".
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ESPEN guideline clinical nutrition in neurology. Clin Nutr 2018; 37:354-396. [DOI: 10.1016/j.clnu.2017.09.003] [Citation(s) in RCA: 193] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 12/12/2022]
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Abstract
Approximately half of neurological and geriatric inpatients suffer from oropharyngeal dysphagia. This often leads to pneumonia, malnutrition and dehydration; however, the underlying dysphagia is frequently not diagnosed and treated. This is particularly the case for patients with so-called silent aspiration. Knowledge on the physiology of swallowing, including the central nervous system control of swallowing and the therapeutic options have achieved considerable progress in recent years. In particular, the increasing implementation of flexible endoscopic evaluation of swallowing (FEES) has significantly contributed to this knowledge. It provides the ability to identify the individual pattern of oropharyngeal dysphagia leading to a suitable selection of therapeutic and compensatory strategies for individual patients. The various therapeutic options range from modification of the consistency of the diet, over diverse logopedic strategies and stimulation techniques up to interventional procedures.
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Affiliation(s)
- R Wirth
- Klinik für Altersmedizin und Frührehabilitation, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Deutschland.
| | - R Dziewas
- Klinik für Allgemeine Neurologie, Universitätsklinik Münster, Münster, Deutschland
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European Society for Swallowing Disorders FEES Accreditation Program for Neurogenic and Geriatric Oropharyngeal Dysphagia. Dysphagia 2017; 32:725-733. [PMID: 28779300 PMCID: PMC5674114 DOI: 10.1007/s00455-017-9828-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 07/27/2017] [Indexed: 01/18/2023]
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Rumbach AF, Cremer R, Chatwood A, Fink S, Haider S, Yee M. The Challenges of Dysphagia Management and Rehabilitation in Two Complex Cases Post Chemical Ingestion Injury. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2016; 25:470-480. [PMID: 27626140 DOI: 10.1044/2016_ajslp-15-0043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 03/03/2016] [Indexed: 06/06/2023]
Abstract
PURPOSE Dysphagia is common sequelae of chemical ingestion injury, resulting from damage to critical swallowing structures. From a speech-language pathology perspective, this study outlines the physiological deficits in 2 individuals with severe injury (1 woman, acid; 1 man, alkali) and the pattern of dysphagia rehabilitation and recovery. METHOD A retrospective chart review of clinical and instrumental assessments was conducted to examine swallow characteristics and speech-language pathology management (compensatory and rehabilitation strategies) at multiple time points. RESULTS Chemical ingestion injury resulted in severe pharyngeal dysphagia for both participants, warranting speech-language pathology management. Dysphagia was characterized by poor base of tongue mobility and reduced laryngeal excursion. Decreased airway patency and protection, secondary to mucosal sloughing, widespread edema, and structural deficits necessitated tracheostomy. Recovery was complicated by physical alterations of pharyngeal and laryngeal structures (e.g., interarytenoid adhesions) and esophageal strictures. Participant 1 was discharged (Day 135) consuming a texture-modified diet; Participant 2 remained nil by mouth (Day 329). CONCLUSIONS Dysphagia recovery subsequent to chemical ingestion is protracted and complex. Clinical outcomes may be improved through individualized and intensive rehabilitation by speech-language pathologists.
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Affiliation(s)
| | - Rebecca Cremer
- Royal Brisbane and Women's Hospital, Metro North Hospital Health Service, Queensland Health, Brisbane, Australia
| | | | - Sari Fink
- The University of Queensland, Australia
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Recognizing the Importance of Dysphagia: Stumbling Blocks and Stepping Stones in the Twenty-First Century. Dysphagia 2016; 32:78-82. [PMID: 27571768 PMCID: PMC5306342 DOI: 10.1007/s00455-016-9746-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 08/16/2016] [Indexed: 12/02/2022]
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Dziewas R, Glahn J, Helfer C, Ickenstein G, Keller J, Ledl C, Lindner-Pfleghar B, G Nabavi D, Prosiegel M, Riecker A, Lapa S, Stanschus S, Warnecke T, Busse O. Flexible endoscopic evaluation of swallowing (FEES) for neurogenic dysphagia: training curriculum of the German Society of Neurology and the German stroke society. BMC MEDICAL EDUCATION 2016; 16:70. [PMID: 26911194 PMCID: PMC4766659 DOI: 10.1186/s12909-016-0587-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 02/08/2016] [Indexed: 06/05/2023]
Abstract
BACKGROUND Neurogenic dysphagia is one of the most frequent and prognostically relevant neurological deficits in a variety of disorders, such as stroke, parkinsonism and advanced neuromuscular diseases. Flexible endoscopic evaluation of swallowing (FEES) is now probably the most frequently used tool for objective dysphagia assessment in Germany. It allows evaluation of the efficacy and safety of swallowing, determination of appropriate feeding strategies and assessment of the efficacy of different swallowing manoeuvres. The literature furthermore indicates that FEES is a safe and well-tolerated procedure. In spite of the huge demand for qualified dysphagia diagnostics in neurology, a systematic FEES education has not yet been established. RESULTS The structured training curriculum presented in this article aims to close this gap and intends to enforce a robust and qualified FEES service. As management of neurogenic dysphagia is not confined to neurologists, this educational programme is applicable to other clinicians and speech-language therapists with expertise in dysphagia as well. CONCLUSION The systematic education in carrying out FEES across a variety of different professions proposed by this curriculum will help to spread this instrumental approach and to improve dysphagia management.
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Affiliation(s)
- Rainer Dziewas
- Department of Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Jörg Glahn
- Department of Neurology, Johannes Wesling Klinikum Minden, Minden, Germany.
| | - Christine Helfer
- ENT and Neurology Departments, Vivantes Klinikum Neukölln, Berlin, Germany.
| | - Guntram Ickenstein
- Department of Neurology and Stroke Unit, HELIOS Klinikum Aue, Aue, Germany.
| | - Jochen Keller
- St. Martinus Hospital, Clinic for Acute Geriatrics, Düsseldorf, Germany.
| | | | | | - Darius G Nabavi
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany.
| | | | - Axel Riecker
- Department of Neurology, University of Ulm, Ulm, Germany.
- Reha Nova, Clinic for neurological and neurosurgical rehabilitation, Cologne, Germany.
| | - Sriramya Lapa
- Department of Neurology, ZNN, Johann Wolfgang Goethe University, Frankfurt am Main, Germany.
| | | | - Tobias Warnecke
- Department of Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Otto Busse
- DSG and DGN Office, Reinhardtstraße 27 C, 10117, Berlin, Germany.
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Dysphagia--a common, transient symptom in critical illness polyneuropathy: a fiberoptic endoscopic evaluation of swallowing study*. Crit Care Med 2015; 43:365-72. [PMID: 25377021 DOI: 10.1097/ccm.0000000000000705] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Critical illness polyneuropathy is a common disorder in the neurological ICU. Dysphagia is well known to deteriorate outcome in the ICU. The prevalence of dysphagia in critical illness polyneuropathy is not known. The aim of this study was to evaluate the prevalence of dysphagia in critical illness polyneuropathy using fiberoptic endoscopic evaluation of swallowing. DESIGN Prospective, cohort study. SETTING Neurological rehabilitation ICU. PATIENTS Twenty-two patients with critical illness polyneuropathy. INTERVENTIONS Clinical swallowing examination and serial fiberoptic endoscopic evaluation of swallowing (days 3, 14, and 28 after admission). MEASUREMENTS AND MAIN RESULTS Swallowing of saliva, pureed consistencies, and liquids was tested using fiberoptic endoscopic evaluation of swallowing at three different time points. The penetration-aspiration scale by Rosenbek et al and the secretion severity rating scale by Murray et al were used for grading. Functional outcome after rehabilitation was assessed using the functional independence measure.: Pathologic swallowing was found in 20 of 22 patients (91%). Hypesthesia of laryngeal structures was found in 17 of 22 patients (77%) during the first fiberoptic endoscopic evaluation of swallowing. Over the 4-week follow-up period, laryngeal hypesthesia resolved in 75% of affected cases. Pureed consistencies were swallowed safely in 18 of 22 cases (82%), whereas liquids and saliva showed high aspiration rates (13 of 17 [78%] and 10 of 22 [45%], respectively). Swallowing function recovered completely in 21 of 22 (95%) within 4 weeks. CONCLUSIONS Dysphagia is frequent among patients with critical illness polyneuropathy treated in the ICU. Old age, chronic obstructive pulmonary disease, the mode of mechanical ventilation, the prevalence of tracheal tubes, and behavioral "learned nonuse" may all be contributing factors for the development of dysphagia in critical illness polyneuropathy. Complete recovery occurs in a high percentage of affected individuals within 4 weeks.
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Rumbach AF, Ward EC, Zheng C, Cornwell P. Charting the recovery of dysphagia in two complex cases of post-thermal burn injury: Physiological characteristics and functional outcomes. SPEECH LANGUAGE AND HEARING 2015. [DOI: 10.1179/2050572815y.0000000002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Howle AA, Baguley IJ, Brown L. Management of Dysphagia Following Traumatic Brain Injury. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2014. [DOI: 10.1007/s40141-014-0064-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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[Oral feeding of long-term ventilated patients with a tracheotomy tube. Underestimated danger of dysphagia]. Med Klin Intensivmed Notfmed 2014; 110:55-60. [PMID: 24989074 DOI: 10.1007/s00063-014-0397-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 05/19/2014] [Accepted: 06/10/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND In long-term mechanically ventilated patients, dysphagia is a common and potentially life-threatening complication, which can lead to aspiration and pneumonia. Nevertheless, many intensive care unit (ICU) patients are fed by mouth without evaluation of their deglutition capability. OBJECTIVE The goal of this work was to evaluate the prevalence of aspiration due to swallowing disorders in long-term ventilated patients who were fed orally in the ICU while having a blocked tracheotomy tube. METHODS In all, 43 patients participated-each underwent a fiberoptic investigation of deglutition on the day of admission to the rehabilitation clinic. RESULTS A total of 65 % of the patients aspirated, 71 % of these silently. There were no associations between aspiration and any of the following: gender, indication for mechanical ventilation (underlying disease) or the duration of intubation and ventilation by tracheotomy tube. However, the association between aspiration and age was statistically significant (p = 0.041). Aspirating patients were older (arithmetic mean = 70 years, median = 74 years) than patients who did not aspirate (arithmetic mean = 66 years, median = 67 years). CONCLUSION Intubation and add-on tracheotomies can lead to potentially life-threatening swallowing disorders that cause aspiration, independent of the underlying disease. Before feeding long-term mechanically ventilated patients by mouth, their ability to swallow needs to be investigated using fiberoptic endoscopic evaluation of swallowing (FEES) or a saliva dye test, if a cuff deflation and the use of a speaking valve are possible during spontaneous respiration.
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Moraes DP, Sassi FC, Mangilli LD, Zilberstein B, de Andrade CRF. Clinical prognostic indicators of dysphagia following prolonged orotracheal intubation in ICU patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R243. [PMID: 24138781 PMCID: PMC4056041 DOI: 10.1186/cc13069] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 08/27/2013] [Indexed: 11/24/2022]
Abstract
Introduction The development of postextubation swallowing dysfunction is well documented in the literature with high prevalence in most studies. However, there are relatively few studies with specific outcomes that focus on the follow-up of these patients until hospital discharge. The purpose of our study was to determine prognostic indicators of dysphagia in ICU patients submitted to prolonged orotracheal intubation (OTI). Methods We conducted a retrospective, observational cohort study from 2010 to 2012 of all patients over 18 years of age admitted to a university hospital ICU who were submitted to prolonged OTI and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist. The prognostic factors analyzed included dysphagia severity rate at the initial swallowing assessment and at hospital discharge, age, time to initiate oral feeding, amount of individual treatment, number of orotracheal intubations, intubation time and length of hospital stay. Results After we excluded patients with neurologic diseases, tracheostomy, esophageal dysphagia and those who were submitted to surgical procedures involving the head and neck, our study sample size was 148 patients. The logistic regression model was used to examine the relationships between independent variables. In the univariate analyses, we found that statistically significant prognostic indicators of dysphagia included dysphagia severity rate at the initial swallowing assessment, time to initiate oral feeding and amount of individual treatment. In the multivariate analysis, we found that dysphagia severity rate at the initial swallowing assessment remained associated with good treatment outcomes. Conclusions Studies of prognostic indicators in different populations with dysphagia can contribute to the design of more effective procedures when evaluating, treating, and monitoring individuals with this type of disorder. Additionally, this study stresses the importance of the initial assessment ratings.
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Systematic review and evidence based recommendations on texture modified foods and thickened fluids for adults (≥18 years) with oropharyngeal dysphagia. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.clnme.2013.05.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Brown CVR, Hejl K, Mandaville AD, Chaney PE, Stevenson G, Smith C. Swallowing dysfunction after mechanical ventilation in trauma patients. J Crit Care 2010; 26:108.e9-13. [PMID: 20869841 DOI: 10.1016/j.jcrc.2010.05.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Revised: 04/30/2010] [Accepted: 05/16/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Swallowing dysfunction can occur after mechanical ventilation, leading to complications such as aspiration and pneumonia. After mechanical ventilation, authors have recommended evaluating patients with contrast studies or endoscopy to identify patients at risk for swallowing dysfunction and aspiration. The purpose of the study was to determine if a bedside swallowing evaluation (BSE) can identify patients with swallowing dysfunction after mechanical ventilation. METHODS This is a 1-year (2008) prospective study of all adult trauma patients admitted to the intensive care unit requiring mechanical ventilation. Upon separation from mechanical, all patients received a BSE. The BSE used mental status, facial symmetry, swallow reflex, and oral ice chips and water to identify swallowing dysfunction. Patients who passed the BSE were advanced to oral intake per physician orders, whereas patients who failed the BSE were allowed nothing by mouth. RESULTS A total of 345 patients were included; 54 died before separation from mechanical ventilation and were excluded. The remaining 291 patients underwent BSE after separation from mechanical ventilation, with 143 (49%) passing and 148 (51%) failing. Patients who failed the BSE required mechanical ventilation longer than those who passed (14 ± 13 vs 5 ± 20 days, P = .001). In addition, only 23% of patients extubated within 72 hours failed the BSE, whereas 78% of those intubated more than 72 hours failed the BSE (P < .001). All patients who passed the BSE were discharged from the hospital without a clinical aspiration event. Independent risk factors for failure of BSE included tracheostomy, older age, prolonged mechanical ventilation, delirium tremens, traumatic brain injury, and spine fracture. Three (2%) patients who failed the BSE had a clinical aspiration event despite taking nothing by mouth. CONCLUSIONS A simple BSE can be used to identify patients at risk for swallowing dysfunction after mechanical ventilation. More importantly, BSE can safely clear patients without swallowing dysfunction, avoiding costly and time-consuming contrast studies or endoscopic evaluation.
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Safaz I, Alaca R, Yasar E, Tok F, Yilmaz B. Medical complications, physical function and communication skills in patients with traumatic brain injury: A single centre 5-year experience. Brain Inj 2009; 22:733-9. [DOI: 10.1080/02699050802304714] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Bágyi K, Haczku A, Márton I, Szabó J, Gáspár A, Andrási M, Varga I, Tóth J, Klekner A. Role of pathogenic oral flora in postoperative pneumonia following brain surgery. BMC Infect Dis 2009; 9:104. [PMID: 19563632 PMCID: PMC2709628 DOI: 10.1186/1471-2334-9-104] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Accepted: 06/29/2009] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Post-operative pulmonary infection often appears to result from aspiration of pathogens colonizing the oral cavity. It was hypothesized that impaired periodontal status and pathogenic oral bacteria significantly contribute to development of aspiration pneumonia following neurosurgical operations. Further, the prophylactic effects of a single dose preoperative cefazolin on the oral bacteria were investigated. METHODS A matched cohort of 18 patients without postoperative lung complications was compared to 5 patients who developed pneumonia within 48 hours after brain surgery. Patients waiting for elective operation of a single brain tumor underwent dental examination and saliva collection before surgery. Bacteria from saliva cultures were isolated and periodontal disease was scored according to type and severity. Patients received 15 mg/kg cefazolin intravenously at the beginning of surgery. Serum, saliva and bronchial secretion were collected promptly after the operation. The minimal inhibitory concentrations of cefazolin regarding the isolated bacteria were determined. The actual antibiotic concentrations in serum, saliva and bronchial secretion were measured by capillary electrophoresis upon completion of surgery. Bacteria were isolated again from the sputum of postoperative pneumonia patients. RESULTS The number and severity of coexisting periodontal diseases were significantly greater in patients with postoperative pneumonia in comparison to the control group (p = 0.031 and p = 0.002, respectively). The relative risk of developing postoperative pneumonia in high periodontal score patients was 3.5 greater than in patients who had low periodontal score (p < 0.0001). Cefazolin concentration in saliva and bronchial secretion remained below detectable levels in every patient. CONCLUSION Presence of multiple periodontal diseases and pathogenic bacteria in the saliva are important predisposing factors of postoperative aspiration pneumonia in patients after brain surgery. The low penetration rate of cefazolin into the saliva indicates that its prophylactic administration may not be sufficient to prevent postoperative aspiration pneumonia. Our study suggests that dental examination may be warranted in order to identify patients at high risk of developing postoperative respiratory infections.
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Affiliation(s)
- Kinga Bágyi
- Faculty of Dentistry, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Angela Haczku
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ildikó Márton
- Faculty of Dentistry, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Judit Szabó
- Institute of Medical Microbiology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Attila Gáspár
- Institute of Inorganic and Analytical Chemistry, University of Debrecen, Debrecen, Hungary
| | - Melinda Andrási
- Institute of Inorganic and Analytical Chemistry, University of Debrecen, Debrecen, Hungary
| | - Imre Varga
- Department of Pulmonology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Judit Tóth
- Department of Oncology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Almos Klekner
- Department of Neurosurgery, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
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Bágyi K, Márton I, Szabó J, Andrási M, Gáspár A, Varga I, Bognár L, Klekner A. Efficacy of pre-operative cephalosporin prophylaxis in controlling pathogenic oral bacteria growth in comatose patients. J Med Microbiol 2008; 57:128-129. [DOI: 10.1099/jmm.0.47381-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Kinga Bágyi
- Faculty of Dentistry, Medical and Health Science Centre, University of Debrecen, Debrecen, Hungary
| | - Ildikó Márton
- Faculty of Dentistry, Medical and Health Science Centre, University of Debrecen, Debrecen, Hungary
| | - Judit Szabó
- Institute of Medical Microbiology, Medical and Health Science Centre, University of Debrecen, Debrecen, Hungary
| | - Melinda Andrási
- Department of Inorganic and Analytical Chemistry, Medical and Health Science Centre, University of Debrecen, Debrecen, Hungary
| | - Attila Gáspár
- Department of Inorganic and Analytical Chemistry, Medical and Health Science Centre, University of Debrecen, Debrecen, Hungary
| | - Imre Varga
- Department of Pulmonology, Medical and Health Science Centre, University of Debrecen, Debrecen, Hungary
| | - László Bognár
- Department of Neurosurgery, Medical and Health Science Centre, University of Debrecen, Debrecen, Hungary
| | - Almos Klekner
- Department of Neurosurgery, Medical and Health Science Centre, University of Debrecen, Debrecen, Hungary
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Brady SL, Darragh M, Escobar NG, O'Neil K, Pape TLB, Rao N. Persons with disorders of consciousness: are oral feedings safe/effective? Brain Inj 2007; 20:1329-34. [PMID: 17378224 DOI: 10.1080/02699050601111435] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PRIMARY OBJECTIVE Evaluate the safety and efficacy of providing oral feedings to persons early in coma recovery following a severe brain injury. RESEARCH DESIGN Descriptive, retrospective study. METHODS AND PROCEDURES Medical chart reviews of all patients admitted to a rehabilitation hospital following severe brain injury. MAIN OUTCOMES AND RESULTS Twenty-five patients met the inclusion criteria, 22 had a tracheostomy, and all were NPO. Subjects were divided into two cohorts. Group 1, n=10, mean age 43.5 years, received oral feedings early in coma recovery. Group 2, n=15, mean age 45.2 years, did not. Group 1, 30% returned to an oral diet of three meals daily at discharge from inpatient rehabilitation as compared to 40% in group 2 (chi2 = 0.260, p = 0.610). Average cost of care for group 1 = US$45 759 and group 2 = US$41 056 (p = 0.634). CONCLUSION Safe therapeutic oral feedings, in accordance with findings from instrumental swallowing examinations, are possible for patients with disordered consciousness. The therapeutic oral feedings do not significantly increase the cost of care, but the effectiveness of oral feedings early in coma recovery requires further investigation.
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Affiliation(s)
- Susan L Brady
- Marianjoy Rehabilitation Hospital, 26 W 171 Roosevelt Road, Wheaton, Illinois 60187, USA.
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Sharma OP, Oswanski MF, Singer D, Buckley B, Courtright B, Raj SS, Waite PJ, Tatchell T, Gandaio A. Swallowing Disorders in Trauma Patients: Impact of Tracheostomy. Am Surg 2007. [DOI: 10.1177/000313480707301107] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Tracheostomy is associated with increased aspiration rates, and swallowing disorders have not been well-studied in trauma patients with tracheostomy. Swallowing evaluations were conducted in 224 patients (102 trauma and 122 nontrauma patients). Half of the patients in each group had tracheostomies. Bedside swallow studies were conducted in 40 patients, videofluoroscopy swallow studies in 100 patients, and both studies in 84 patients. χ2, Fisher's exact test, Cramer's V, and descriptive statistics were used for data analysis. Aspiration occurred in 35 per cent (36 of 102) of trauma patients with or without tracheostomy and in 36 per cent (22 of 61) of nontrauma patients with tracheostomy. Aspiration with and without penetration was observed in 54 per cent of trauma patients (55% with tracheostomy) compared with 67 per cent of all nontrauma patients (61% with tracheostomy). Trauma patients with head injuries exhibited 41 per cent (26 of 63) aspiration and 68 per cent (43 of 63) dysphagia compared with 26 per cent (10 of 39) and 59 per cent (23 of 39) in trauma patients with other injuries. There was a lower incidence of dysphagia in trauma patients (65% versus 81% in nontrauma) and in patients with tracheostomy (71% versus 77% without tracheostomy). Tracheostomy was not associated with increased dysphagia or aspiration.
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Affiliation(s)
| | | | | | | | - Beth Courtright
- Speech Language Pathology, The Toledo Hospital & Toledo Children's Hospital, Toledo, Ohio
| | | | - Phillip J. Waite
- Health, Physical Education, and Recreation, Utah State University, Logan, Utah; and, Toledo, Ohio
| | - Thomas Tatchell
- Health Science and Human Service, The University of Toledo, Toledo, Ohio
| | - Angela Gandaio
- Health Science and Human Service, The University of Toledo, Toledo, Ohio
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Humbert IA, Robbins J. Normal swallowing and functional magnetic resonance imaging: a systematic review. Dysphagia 2007; 22:266-75. [PMID: 17440775 PMCID: PMC2631032 DOI: 10.1007/s00455-007-9080-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2006] [Accepted: 01/29/2007] [Indexed: 10/23/2022]
Abstract
Unknowns about the neurophysiology of normal and disordered swallowing have stimulated exciting and important research questions. Previously, these questions were answered using clinical and animal studies. However, recent technologic advances have moved brain-imaging techniques such as functional magnetic resonance imaging (fMRI) to the forefront of swallowing neurophysiology research. This systematic review has summarized the methods and results of studies of swallowing neurophysiology of healthy adults using fMRI. A comprehensive electronic and hand search for original research was conducted, including few search limitations to yield the maximum possible number of relevant studies. The participants, study design, tasks, and brain image acquisition were reviewed and the results indicate that the primary motor and sensory areas were most consistently active in the healthy adult participants across the relevant studies. Other prevalent areas of activation included the anterior cingulate cortex and insular cortex. Review limitations and suggested future directions are also discussed.
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Affiliation(s)
- Ianessa A Humbert
- William S. Middleton Memorial Veterans Hospital, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin 53705, USA.
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Clavé P, de Kraa M, Arreola V, Girvent M, Farré R, Palomera E, Serra-Prat M. The effect of bolus viscosity on swallowing function in neurogenic dysphagia. Aliment Pharmacol Ther 2006; 24:1385-94. [PMID: 17059520 DOI: 10.1111/j.1365-2036.2006.03118.x] [Citation(s) in RCA: 268] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
AIM To assess the pathophysiology and treatment of neurogenic dysphagia. METHODS 46 patients with brain damage, 46 with neurodegenerative diseases and eight healthy volunteers were studied by videofluoroscopy while swallowing 3-20 mL liquid (20.4 mPa s), nectar (274.4 mPa s) and pudding (3931.2 mPa s) boluses. RESULTS Volunteers presented a safe and efficacious swallow, short swallow response (< or =740 ms), fast laryngeal closure (< or =160 ms) and strong bolus propulsion (> or =0.33 mJ). Brain damage patients presented: (i) 21.6% aspiration of liquids, reduced by nectar (10.5%) and pudding (5.3%) viscosity (P < 0.05) and (ii) 39.5% oropharyngeal residue. Neurodegenerative patients presented: (i) 16.2% aspiration of liquids, reduced by nectar (8.3%) and pudding (2.9%) viscosity (P < 0.05) and (ii) 44.4% oropharyngeal residue. Both group of patients presented prolonged swallow response (> or =806 ms) with a delay in laryngeal closure (> or =245 ms), and weak bolus propulsion forces (< or =0.20 mJ). Increasing viscosity did not affect timing of swallow response or bolus kinetic energy. CONCLUSIONS Patients with neurogenic dysphagia presented high prevalence of videofluoroscopic signs of impaired safety and efficacy of swallow, and were at high risk of respiratory and nutritional complications. Impaired safety is associated with slow oropharyngeal reconfiguration and impaired efficacy with low bolus propulsion. Increasing bolus viscosity greatly improves swallowing function in neurological patients.
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Affiliation(s)
- P Clavé
- Department of Surgery, Hospital de Mataró, Unitat d'Exploracions Funcionals Digestives, Mataró, Spain
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Abstract
The association of cervical spinal cord injury and swallowing disorders is clinically well recognized. This study was performed to determine the clinical significance and the outcome of deglutition disorders observed in the initial treatment of cervical spinal cord injury in our tertiary care spinal cord injury unit. All patients with cervical spinal cord injury admitted to our facility for initial care between January 1997 and December 2000 were included in our study. Prevalence of dysphagia and frequency of pneumonia were determined. An assessment of deglutition at discharge was performed. Dysphagia was diagnosed in 26 of the 73 patients with cervical spinal cord injury. Tracheostomy and duration of orotracheal intubation are associated with dysphagia. The disorder necessitated dietary restrictions in 18 patients. Six of these patients had to be discharged with a percutaneous enterogastric feeding tube; seven had persistent problems not resulting in dietary restrictions. The incidence of late pneumonia was significantly increased with two associated deaths. Dysphagia is a serious complication associated with prolonged requirement for ventilatory support. Patients have to be monitored closely because the incidence of pneumonia is increased. While the situation improves for most patients, a significant number of patients need a percutaneous enterogastric feeding tube as a permanent solution.
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Affiliation(s)
- Rainer Abel
- Department of Orthopedic Surgery and Rehabilitation, Orthopädische Universitätsklinik Heidelberg, Heidelberg, Germany.
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Abstract
Dysphagia, or the inability to swallow normally, is a feature of a number of neurological conditions. It is found in both paediatric and adult populations, but the scope of this article is limited to the adult neurogenic population. The normal swallow is a complex and highly coordinated activity, any part of which may be disturbed by neurological illness or injury. Assessment of dysphagia is normally undertaken by speech and language therapists in conjunction with the multidisciplinary team. A bedside screening assessment may be augmented by instrumental assessment, such as videofluoroscopy, in cases where silent aspiration of food or liquid into the lungs is suspected. Dysphagia is treated using a variety of strategies, depending on the presenting symptoms. Individuals with dysphagia following traumatic brain injury present with particular difficulties, relating to impairments of cognition, communication and behavioural control. A description of the normal swallow is presented below with a review of dysphagic disorders, assessment methods and management. This is followed by a case account of a young man with dysphagia subsequent to traumatic brain injury to highlight some of the difficulties which can be encountered in the management of dysphagia.
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Affiliation(s)
- Victoria Mayer
- Scottish Brain Injury Rehabilitation Service, Charles Bell Pavilion, Astley Ainslie Hospital, Edinburgh.
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Humar M, Pischke SE, Loop T, Hoetzel A, Schmidt R, Klaas C, Pahl HL, Geiger KK, Pannen BHJ. Barbiturates Directly Inhibit the Calmodulin/Calcineurin Complex: a Novel Mechanism of Inhibition of Nuclear Factor of Activated T Cells. Mol Pharmacol 2004; 65:350-61. [PMID: 14742677 DOI: 10.1124/mol.65.2.350] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Barbiturates are frequently used for the treatment of intracranial hypertension after brain injury but their application is associated with a profound increase in the infection rate. The mechanism of barbiturate-induced failure of protective immunity is still unknown. We provide evidence that nuclear factor of activated T cells (NFAT), an essential transcription factor in T cell activation, is a target of barbiturate-mediated immunosuppression in human T lymphocytes. Treatment of primary CD3+ lymphocytes with barbiturates inhibited the PMA and ionomycin induced increase in DNA binding of NFAT, whereas the activity of other transcription factors, such as Oct-1, SP-1, or the cAMP response element-binding protein, remained unaffected. Moreover, barbiturates suppressed the expression of a luciferase reporter gene under control of NFAT (stably transfected Jurkat T cells), and of the cytokine genes interleukin-2 and interferon-gamma that contain functional binding motifs for NFAT within their regulatory promotor domains (human peripheral blood CD3+ lymphocytes). Neither GABA receptor-initiated signaling nor direct interactions of barbiturates with nuclear proteins affected the activity of NFAT. In contrast, barbiturates suppressed the calcineurin-dependent dephosphorylation of NFAT in intact T cells and also inhibited the enzymatic activity of calcineurin in a cell-free system, excluding upstream regulation. Thus, our results demonstrate a novel mechanism of direct inhibition of the calcineurin/calmodulin complex that may explain some of the known immunosuppressive effects associated with barbiturate treatment.
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Affiliation(s)
- Matjaz Humar
- Department of Anesthesiology and Critical Care Medicine, University Hospital Freiburg, Freiburg, Germany
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Morgan A, Ward E, Murdoch B, Kennedy B, Murison R. Incidence, characteristics, and predictive factors for Dysphagia after pediatric traumatic brain injury. J Head Trauma Rehabil 2003; 18:239-51. [PMID: 12802166 DOI: 10.1097/00001199-200305000-00002] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE (1) To establish an incidence figure for dysphagia in a population of pediatric traumatic brain injury (TBI) cases; (2) to provide descriptive data on the admitting characteristics, patterns of resolution, and outcomes of children with and without dysphagia after TBI; and (3) to identify any factors present at admission that may predict dysphagia. PARTICIPANTS A total of 1,145 children consecutively admitted to an acute care setting for traumatic brain injury between July 1995 and July 2000. MAIN OUTCOME MEASURE Medical parameters relating to dysphagia based on medical chart review. RESULTS (1) Dysphagia incidence figure of 5.3% across all pediatric head injury admissions. Incidence figures of 68% for severe TBI, 15% for moderate TBI, and only 1% for mild brain injury. (2) Statistically significant differences were found between the dysphagic and nondysphagic subgroups on the variables of length of stay, length of ventilation, Glasgow Coma Scale (GCS), computed tomography classification, duration of speech pathology intervention, supplemental feeding duration, duration until initiation of oral intake (DIOF), duration to total oral intake (DTOF), and period of time from the initiation of intake until achievement of total oral intake (DI-TOF). (3) Significant predictive factors for dysphagia included GCS < 8.5 and a ventilation period in excess of 1.5 days. CONCLUSION The provision of incidence data and predictive factors for dysphagia will enable clinicians in acute care settings to allocate resources necessary to deal with the predicted number of dysphagia cases in a pediatric population, and assist in predicting patients who are at risk for dysphagia following TBI. Early detection of patients with swallowing dysfunction will be aided by these data, in turn helping to facilitate effective medical and speech pathology intervention via assisting the reduction of medical complications such as aspiration pneumonia.
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Affiliation(s)
- Angela Morgan
- Department of Speech Pathology and Audiology, University of Queensland, Brisbane, Queensland, Australia
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O'Neil-Pirozzi TM, Momose KJ, Mello J, Lepak P, McCabe M, Connors JJ, Lisiecki DJ. Feasibility of swallowing interventions for tracheostomized individuals with severely disordered consciousness following traumatic brain injury. Brain Inj 2003; 17:389-99. [PMID: 12745711 DOI: 10.1080/0269905031000070251] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PRIMARY OBJECTIVE To report the ability of 12 tracheostomized acute rehabilitation hospital inpatients with severely disordered consciousness post-traumatic brain injury (TBI) to participate in an objective swallowing assessment. RESEARCH DESIGN Post hoc analysis of data from a larger, prospective blinded comparison study. METHODS AND PROCEDURES Subjects completed a modified barium swallow (MBS) study. Food/drink and tracheostomy tube management recommendations were made. MAIN OUTCOMES AND RESULTS All subjects participated successfully during an MBS. Post-MBS, 10 subjects began receiving small amounts of food and/or drink. Prior to hospital discharge, all subjects received some food and/or drink and were extubated. Subjects were deemed representative of this patient population and, from a swallowing perspective, other tracheostomized patient populations at the same facility. CONCLUSIONS Clinicians should routinely consider tracheostomized, acute rehabilitation hospital inpatients with severely disordered consciousness post-TBI potential MBS candidates. Implications and continued research needs are discussed.
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Morgan A, Ward E, Murdoch B, Bilbie K. Acute characteristics of pediatric Dysphagia subsequent to traumatic brain injury: videofluoroscopic assessment. J Head Trauma Rehabil 2002; 17:220-41. [PMID: 12086576 DOI: 10.1097/00001199-200206000-00004] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To document the acute characteristics of swallowing impairment in a group of children post moderate/severe traumatic brain injury (TBI) by means of videofluoroscopy. PARTICIPANTS Eighteen children with moderate/severe TBI. MAIN OUTCOME MEASURE Videofluoroscopy at an average of 27.7 days post-injury. RESULTS Subjects demonstrated a range of dysphagia severity levels: mild-moderate (n = 8), moderate (n = 6), moderate-severe (n = 3), and severe (n = 1) and had a combination of oral and pharyngeal phase characteristics. More specifically, observable features or physiological impairments that were identified included reduced lingual control, hesitancy of tongue movement, repetitive tongue pumping, the presence of aspiration (including silent aspiration), delayed swallow reflex trigger, reduced laryngeal elevation and closure, and reduced peristalsis. CONCLUSIONS These data highlight the diversity of swallowing deficits and dysphagia severity levels in children following TBI and suggest that the former are consistent with a pattern of oropharyngeal impairments.
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Affiliation(s)
- Angela Morgan
- Department of Speech Pathology and Audiology, The University of Queensland, St. Lucia, Brisbane, Queensland
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Sawczuk A, Mosier KM. Neural control of tongue movement with respect to respiration and swallowing. ACTA ACUST UNITED AC 2001; 12:18-37. [PMID: 11349959 DOI: 10.1177/10454411010120010101] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The tongue must move with remarkable speed and precision between multiple orofacial motor behaviors that are executed virtually simultaneously. Our present understanding of these highly integrated relationships has been limited by their complexity. Recent research indicates that the tongue s contribution to complex orofacial movements is much greater than previously thought. The purpose of this paper is to review the neural control of tongue movement and relate it to complex orofacial behaviors. Particular attention will be given to the interaction of tongue movement with respiration and swallowing, because the morbidity and mortality associated with these relationships make this a primary focus of many current investigations. This review will begin with a discussion of peripheral tongue muscle and nerve physiology that will include new data on tongue contractile properties. Other relevant peripheral oral cavity and oropharyngeal neurophysiology will also be discussed. Much of the review will focus on brainstem control of tongue movement and modulation by neurons that control swallowing and respiration, because it is in the brainstem that orofacial motor behaviors sort themselves out from their common peripheral structures. There is abundant evidence indicating that the neural control of protrusive tongue movement by motoneurons in the ventral hypoglossal nucleus is modulated by respiratory neurons that control inspiratory drive. Yet, little is known of hypoglossal motoneuron modulation by neurons controlling swallowing or other complex movements. There is evidence, however, suggesting that functional segregation of respiration and swallowing within the brainstem is reflected in somatotopy within the hypoglossal nucleus. Also, subtle changes in the neural control of tongue movement may signal the transition between respiration and swallowing. The final section of this review will focus on the cortical integration of tongue movement with complex orofacial movements. This section will conclude with a discussion of the functional and clinical significance of cortical control with respect to recent advances in our understanding of the peripheral and brainstem physiology of tongue movement.
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Affiliation(s)
- A Sawczuk
- Department of Oral Pathology, University of Medicine and Dentistry of New Jersey, Newark 07103-2400, USA
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Abstract
Management of head injury is based on two concepts, proper treatment of the acute insult and the prevention and treatment of secondary insults. The head injured patient is subject to both intracranial and extracranial secondary insults. This paper will review complications related to the central nervous system as well as the pulmonary, infectious, gastrointestinal, and psychiatric complications frequently seen following traumatic brain injury. Complications following head trauma lead to significant acute and chronic morbidity and mortality. It is essential that clinicians be able to recognize and treat these complications in order to more effectively manage head trauma, improve outcome, and care for patients.
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Affiliation(s)
- J G Pilitsis
- Department of Neurological Surgery, Wayne State University, 4201 St. Antoine, 6E, Detroit, MI 48201, USA.
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