Esophageal Dysphagia in Adults: When It Sticks

Esophageal dysphagia is a common yet difficult to diagnose condition. This article underscores the role of detailed patient history and physical examinations, including prompt endoscopic evaluation, for accurate differentiation between esophageal and oropharyngeal dysphagia. The authors discuss the heightened importance of early intervention in certain patient groups, such as elderly individuals and patients with head and neck cancer, to mitigate the risk of malnutrition and infection. The authors delve into etiologic factors highlighting the complexity of clinical presentations and the significance of tailored management strategies.

The Impact of Food-Shaping Techniques on Nutrition, Mealtime Experiences, and Quality of Life for Older Adults in Aged Care Settings: A Systematic Review

OBJECTIVE

Food-shaping methods, particularly for texture-modified foods, present numerous opportunities to improve the visual appeal of food and potentially the nutrition of older people with dysphagia (swallowing difficulty). This review appraises and synthesizes the evidence on the use of food-shaping methods to enhance nutrition in older adults with swallowing difficulties.

METHODS

In August 2022, five electronic databases (PubMed, CINAHL, Scopus, Cochrane Library, and Web of Science) were searched for original research related to the intersection of nutrition, food shaping, and older adults with swallowing difficulties. Characteristics of included studies were described and data from results and findings extracted for analysis across studies.

RESULTS

Eighteen studies met the inclusion criteria and encompassed a variety of settings, including aged care settings (n = 15) and food science laboratories (n = 3). Qualitative and quantitative findings demonstrated a variety of impacts of food shaping for the older adult with swallowing difficulty, including enhanced nutrition and wellbeing. The content themes identified across studies were: links between food shaping and nutrition, shaping food for individual choice, food shaping for enjoyment, a combination of supporting factors, collaborative inter-disciplinary teams and roles, and implementation aligns with local contexts.

CONCLUSION

With recent growth in research on food shaping, the body of studies reviewed identified an influence of food-shaping methods on the nutritional status of older adults with swallowing difficulties. Given the identified potential benefit of food shaping and attention to the visual appeal of food for older people, further research examining links between food shaping and nutrition are warranted.

Diffuse idiopathic skeletal hyperostosis as a cause for dysphagia in a patient with ankylosing spondylitis

BACKGROUND

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by ankylosing spinal alterations which are often asymptomatic but may typically cause back pain and spinal stiffness. Presence of DISH may complicate spinal trauma and lead to unstable fractures requiring surgical intervention. Treatment options include physical activity, symptomatic treatment, local heat application, and optimization of metabolic comorbidities.

CASE

A multimorbid older patient was admitted to the gastroenterological ward for the investigation of progressive dysphagia and weight loss. Gastroscopy revealed a dorsal impression of the esophagus at 25 cm from the incisor. Clinical work-up including computed tomography (CT) and magnetic resonance imaging (MRI) ruled out malignancy but showed ankylosing spondylophytes and non-recent fractures of vertebrae C5-C7, compatible with DISH of the cervicothoracic spine as a cause for the esophageal impression. Notably, imaging diagnostics showed ankylosing spine alterations extending to the lumbar spine and both sacroiliac joints, suggestive of ankylosing spondylitis (AS). Typical imaging characteristics, a history of psoriasis, and positive HLA*B27 status supported the diagnosis of underlying AS in this patient with dysphagia as an unusual primary symptom of DISH. Additionally, pulmonary alterations compatible with a usual interstitial pneumonia (UIP)-like pattern were seen on lung CT.

CONCLUSION

Overlaps among AS, DISH and pulmonary abnormalities including UIP have been described previously; however, they represent unexpected findings in this older patient. This case underlines the importance of interdisciplinary collaboration and consideration of DISH as a differential diagnosis in patients with atypical symptoms.

The Effect of Deep Brain Stimulation on Swallowing Function in Parkinson's Disease: A Narrative Review

Unlike appendicular motor symptoms, such as bradykinesia and rigidity, in Parkinson's disease (PD), which have already been reported to respond well to deep brain stimulation (DBS), there is limited literature on the effects of DBS on swallowing function in patients with PD. The field lacks consensus as there are conflicting reports among existing studies regarding whether swallowing function improves or declines following DBS implantation. This narrative review aims to summarize and analyze the studies published on the effect of DBS on swallowing function in patients with PD. We collated studies published up to February 2020 using a comprehensive electronic database search of PubMed, SCOPUS, EMBASE, and the Cochrane Library. Two reviewers independently assessed the studies using strict inclusion and exclusion criteria. The primary literature search yielded 529 relevant papers. After reading their titles and abstracts and assessing their eligibility based on the full-text, we finally included and reviewed 14 publications. Nine of these studies reported positive effects of DBS on swallowing function and four studies showed no significant positive results. The remaining study showed decreased swallowing function after unilateral subthalamic nucleus-DBS surgery. In conclusion, we found that DBS has the potential to improve swallowing function in patients with PD. However, high-quality evidence is lacking. To clearly elucidate the effect of DBS on swallowing function in patients with PD, high-quality randomized controlled trials should be conducted in the future.

Low tongue strength is associated with oral and cough-related abnormalities in older inpatients

OBJECTIVES

Sarcopenic dysphagia is partly characterized by a decline in the strength of the swallowing muscles. However, its associated characteristics and symptoms are unclear. The aim of this study was to clarify the characteristics and symptoms of swallowing ability associated with low tongue muscle strength, which is one of the swallowing muscles in older adults.

METHODS

This was a cross-sectional study of 197 older patients admitted to the hospital for orthopedic conditions. We measured the maximum tongue pressure (MTP) against the palate. Swallowing-related characteristics were assessed with the Mann assessment of swallowing ability. Sarcopenia was diagnosed using the 2019 Asian Working Group for Sarcopenia.

RESULTS

The mean age of patients was 81.3 ± 7.6 y, and 80.2% of patients were women. Forty-two patients (21.3%) showed low MTP, defined as <20 kPa. Approximately 50% of participants had sarcopenia. Patients in the low MTP group had a significantly higher incidence of sarcopenia compared with the normal MTP group (71.4% vs. 48.4%; P = .008). After adjusting for potential confounders in the multivariate analyses, low MTP was found to be independently associated with abnormalities in tongue coordination (odds ratio [OR]: 5.251; 95% confidence interval [CI], 2.336-11.807; P < .001), oral transit (OR: 5.248; 95% CI, 1.424-19.345; P = .013), cough reflex (OR: 2.709; 95% CI, 1.280-5.733; P = .009), and voluntary cough (OR: 7.786; 95% CI, 3.329-18.208; P < .001).

CONCLUSIONS

Patients with low tongue strength are characterized by abnormal oral and cough-related characteristics.

Airway protection & patterns of dysphagia in infants with down syndrome: Videofluoroscopic swallow study findings & correlations

INTRODUCTION

Down syndrome is a genetic condition that affects 1:737 births. Along with cardiac, otolaryngologic, and developmental anomalies, infants with Down syndrome can have swallowing difficulties resulting in respiratory infections. This study aims to characterize the airway protection and dysphagia seen in infants with Down syndrome.

METHODS

This is a retrospective chart review of infants with Down syndrome who underwent videofluoroscopic swallow studies (VFSS) from 2008 to 2018 at a tertiary children's hospital. Demographic data and VFSS findings were collected.

RESULTS

89.8% (114/127) of infants presented with at least one element of oral dysphagia, while 72.4% (92/127) had at least one element of pharyngeal dysphagia. Sucking skills were classified as abnormal in 63.7% of the patients and bolus formation-control was determined to be deficient (abnormal) in 62.2% of the patients. Oral residuals were present in 37.8% of the patients. With regard to pharyngeal phase, the swallow initiation was considered abnormal in 53.5% of the patients. Pharyngeal residue was present in 17.3% and pharyngo-nasal reflux was present in 27.5% of the patients.

CONCLUSIONS

Swallowing assessments in infants with Down syndrome suspected of dysphagia should be considered, especially in those with any alterations in pulmonary health.

Objective Assessment of Postoperative Swallowing Difficulty Through Ultrasound in Patients Undergoing Thyroidectomy

Swallowing discomfort is a common postoperative complaint in patients undergoing thyroidectomy. Contraction of the strap muscles might cause resistance to elevation of the laryngotracheal unit, and downward movement of the laryngotracheal unit may lead to swallowing discomfort. However, few studies have evaluated the mechanism related to limited laryngotracheal elevation after thyroidectomy. We aimed to objectively verify the presence of postoperative impaired laryngotracheal elevation through ultrasound evaluation in patients undergoing thyroidectomy and evaluate its relationship with limitation of laryngotracheal elevation. This is a prospective clinical study. Among patients undergoing hemithyroidectomy and total thyroidectomy, the patients who were followed up for ≥ 6 months were selected (N = 40). Ultrasound evaluation was done preoperatively and at 1, 3, and 6 months postoperatively. Laryngotracheal movement was recorded and the length of elevation was measured. Symptom after thyroidectomy was evaluated through swallowing-related items of thyroidectomy-related voice questionnaire. Ultrasound evaluation verified the presence of limited laryngotracheal elevation postoperatively in patients undergoing thyroidectomy. After thyroidectomy, the swallowing-related score was significantly increased, and was recovered time-dependently at 1 month. Laryngotracheal elevation showed significant decrease after thyroidectomy. The symptom score of swallowing was significantly correlated with the length of laryngotracheal elevation. Post-thyroidectomy ultrasound evaluation verified that laryngotracheal elevation was significantly impaired. Presence of adhesion between the laryngotracheal unit and the superficial soft tissue was the probable cause of the limitation at 6 months after thyroidectomy. The length of laryngotracheal elevation was related to the symptom score of swallowing after thyroid surgery.

Symptoms of swallowing anxiety in panic disorder patients and associated psychopathologic factors

AIM

The aim of this study was to investigate symptoms of swallowing difficulty in Panic Disorder (PD) patients and the factors associated with these symptoms.

METHODS

In the pre-phase of the study, 22 PD patients who were treated in psychiatry outpatient clinics and who were found to have swallowing difficulty were evaluated. PD patients were asked to write about their thoughts, feelings and behaviors associated with swallowing difficulty. Later, these texts were examined and 41 expressions were identified in which patients described their swallowing difficulty. These expressions were evaluated by mental health workers in the field and twelve different swallowing difficulty items were defined. In the main phase of the study, 119 PD outpatients were evaluated using twelve different swallowing difficulty items and psychometric tests [Panic and Agoraphobia Scale (PAS), Separation Anxiety Symptom Inventory (SASI), Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI-1/STAI-2)].

RESULTS

As a result of the validity and reliability analysis, a valid one-factor instrument with ten items was obtained. Cronbach's alpha value for this measurement tool was 0.89 and it was termed the "Swallowing Anxiety Scale (SAS)". It was found that SAS items "always" accompany PD patients at rates of 5-20.2%. According to hierarchical regression analysis, 35% of SAS scores were explained by PAS, SASI, STAI-2 and BDI scores.

CONCLUSION

Swallowing difficulty items in PD patients involved anxious, phobic and somatic symptoms associated with swallowing. In addition, swallowing difficulty symptoms in PD patients can be confounded with eating disorder symptoms.

Decreased Skeletal Muscle Mass and Risk Factors of Sarcopenic Dysphagia: A Prospective Observational Cohort Study

Background

Dysphagia is a known risk factor for malnutrition and pneumonia. Although sarcopenia is hypothesized to cause dysphagia, its causality remains unclear. Thus, this study aimed to investigate causality and the risk factors for sarcopenic dysphagia.

Methods

We enrolled 95 hospitalized patients aged 65 years or older who had restricted oral intake without dysphagia. The skeletal muscle index and Functional Oral Intake Scale were used to evaluate muscle mass and swallowing ability, respectively. Nutritional status, assessed by body mass index, the Mini Nutritional Assessment-Short Form, and energy intake; activity of daily living, assessed by the Barthel Index; hand-grip strength; duration of oral intake restriction; and cognitive status were measured. Dysphagia (Functional Oral Intake Scale ≤ 5) was determined after 2 months.

Results

The participants' mean age was 83.2 ± 8.0 years; 63% were women. Of the surviving 82 patients, 63 (77%) had sarcopenia and 21 (26%) developed dysphagia, all of whom had sarcopenia (p = .002). Most variables were risk factors for dysphagia on univariate analysis. Decreased skeletal muscle index (odds ratio [OR] 24.0, 95% confidence interval [CI] 3.6-159.0, p = .001), Barthel Index (OR 12.9, 95% CI 2.1-78.4, p = .005), and body mass index (OR 11.4, 95% CI 1.8-70.5, p = .009) were independent predictors of dysphagia in the multivariate analysis.

Conclusion

This study provides evidence for sarcopenic dysphagia and its risk factors. Preventive and therapeutic interventions require further study.

Computer-assisted detection of swallowing difficulty

To evaluate classification performance of a support vector machine (SVM) classifier for diagnosing swallowing difficulty based on the hyoid movement data attained from videofluoroscopic swallowing study, the hyoid kinematics during the swallowing of 2 mL of liquid barium solution were analyzed for 90 healthy volunteers and 116 dysphagic stroke patients. SVM was used to classify the kinematic results as normal or dysfunctional swallowing. Various kernel functions and kernel parameters were used for optimization. Features were selected to find an optimal feature subset and to minimize redundancy. Accuracy, sensitivity, specificity, and area under a receiving operating characteristic curve (AUC) were used to assess the discrimination performance. In 19 out of 26 features, mean comparison revealed a significant difference between healthy subjects and dysphagic patients. By reducing the number of features to 10, an AUC of 0.9269 could be reached. Common features showing the best classification in both kernel functions included forward maximum excursion time, upward maximum excursion time, maximum excursion length, upward maximum velocity time, upward maximum acceleration time, maximum acceleration, maximum acceleration time, and mean acceleration. SVM-based classification method with the use of kernel functions showed an outstanding (AUC of 0.9269) discrimination performance for either healthy or dysphagic hyoid movement during swallowing. We expect that this classification method will be useful as an adjunct diagnostic tool by providing automatic detection of swallowing dysfunction as well as a research tool providing deeper understanding of pathophysiology.

Analysis of resources assisting in coping with swallowing difficulties for patients with Parkinson's disease: a cross-sectional study

BACKGROUND

Malnutrition induced by swallowing difficulties (SD) impairs the quality of life and gives rise to SD-related costs in Parkinson's disease (PD) patients. With results of a swallowing difficulty questionnaire and data of resources specifically obtained such as SD-related costs, caregivers, and dietary therapies, this study is to suggest statistically supported ideas for improvements in arrangements for how participants cope with SD and maintain general well-being.

METHODS

We interviewed 237 PD patients. The SD-related costs involved those incurred by the provision of dietary modifications, care oriented foods, alternatives, and supplements. Dietary therapies included rice porridge and commercially available care foods. The relationships between BMI (body mass index) and the severity of SD assumed in this paper as indicators for general well-being and as resources for coping with SD for PD patients were statistically analyzed.

RESULTS

A lower BMI was found in participants eating porridge consistency rice (p = 0.003) and eating porridge rice is significantly related to the severity of SD (p < 0.0001) and PD (p = 0.002). The severity of SD increased with age and PD duration (p = 0.035, p = 0.0005). Outlays for dietary modifications are the lowest reported here (p < 0.004) but the number of participants using dietary modifications is the largest among the SD-related items (n = 58). Eating care foods were reported for 11 older participants (p < 0.0001), most female (10/11). No lower BMI was found in participants eating care foods when compared with participants eating ordinary foods. Dietary modifications were performed by caregivers (OR: 6.8, CI: 3.1-15.2, p < 0.0001) and were related to the presence of children (OR: 3.4, CI: 1.2-11.4. p = 0.024). Older participants commonly live with spouses and children.

CONCLUSIONS

Severe SD is associated with higher costs of coping with SD. A lower BMI is associated with modified foods, mostly eaten to cope with SD. Presence of caregivers and other persons residing with the participants here are related to dietary modifications but not to care food-related costs. Care foods may be effective in preventing malnutrition although the number who are able to cover the added expenses is limited because of the higher prices and shortage of information on the usefulness of care foods.

Patients with chronic pain and dysphagia (CPD): unmet medical needs and pharmacologic treatment options

BACKGROUND

For properly selected patients experiencing chronic pain, extended-release opioid formulations may represent an appropriate pain management choice. For the many adults, elderly, and children who have medical conditions that make swallowing solid, oral-dose formulations difficult (dysphagia) or painful (odynophagia), this option may be limited. The combination of chronic pain with dysphagia (CPD) presents a challenge to physicians and patients alike when oral opioid analgesia is needed to control pain, but patients are unable to swallow solid, oral dosage forms.

METHODS

A Medline search was performed (1990 to 2013) using the search terms swallowing difficulties, dysphagia, odynophagia, adults, pediatrics, elderly, chronic pain, pain, and opioids. The following websites were searched: American Dysphagia Network, Dysphagia Research Society, World Health Organization, American Pain Society, International Association for the Study of Pain, American Academy of Pain Medicine, and American Society of Interventional Pain Physicians. Chronic pain guidelines from the following professional organizations were searched: American Pain Society, National Comprehensive Cancer Network, American Society of Interventional Pain Physicians, British Geriatric Society, European Society of Medical Oncology, World Health Organization, and the European Association for Palliative Care.

FINDINGS

There is an unmet medical need for greater recognition of dysphagia, awareness of potential problems with medication administration in these patients, recognition of alternative drug formulations that are available for use in CPD, and an appreciation that there are new, solid, oral-dose, opioid formulations in development that can mitigate these issues associated with swallowing difficulty while still providing practical, effective analgesia. Current pharmacologic treatments have limitations; new, prospective opioid formulations in clinical development may offer physicians and patients with CPD effective treatment options while mitigating accidental exposure and abuse liability.

CONCLUSIONS

The number of patients with CPD may be larger than is currently anticipated by healthcare providers. Physicians should proactively include a discussion of dysphagia as part of the patient examination. CPD is an unmet medical need. There are novel opioid formulations in clinical development that address the limitations of current opioid treatments. This manuscript reviews the problems associated with dysphagia on medication administration and adherence, currently available treatment options, and opioid analgesic formulations currently in clinical development.

Preparation and characterization of spironolactone-loaded nano-emulsions for extemporaneous applications

In neonates as well as in adults having swallowing difficulty, oral medication is given through a nasogastric tube making liquid formulations preferable. In this study, we present the high potential of nanometric emulsions formulated by spontaneous surfactant diffusion, as extemporaneous formulations of hydrophobic drug. Spironolactone used as hydrophobic drug model, was incorporated in oil before formulation at a concentration of 13.5mg/g oil. Then, all formulations were evaluated from pharmacotechnical and clinical standpoints, for their use in hospital or community pharmacy. The strength of this new liquid formulation lies on the simplicity, efficiency and reproducibility of their low energy process as on clinical aspects: high dose uniformity, facility to be administered through in nasogastric tube without any retention and a stability of 2 months at least compatible for an extemporaneous use. Moreover, this emulsion presented spironolactone content of 3.75 mg/ml among the most concentrated formulations published.

Gelfoam-induced Swallowing Difficulty after Anterior Cervical Spine Surgery

Symptomatic diffuse idiopathic skeletal hyperostosis (DISH) is not common. Gelfoam is one of the most commonly used topical hemostatic agents. But, in the partially moistened state, air retained in its pores may result in excessive expansion on contact with liquid. The onset of swallowing difficulty after anterior cervical spine surgery due to appling gelfoam is a rare complication. A 77-year-old man with swallowing difficulty was admitted to our hospital and we diagnosed him as DISH confirmed by radiological study. After removing the DISH, patient's symptom was relieved gradually. However, on postoperative day (POD) 7, the symptom recurred but lesser than the preoperative state. We confirmed no hematoma and esophageal perforation on the operation site. We observed him closely and controlled the diet. Three months later, he had no symptom of swallowing difficulty, and was able to be back on a regular diet, including solid foods. We present a complication case of swallowing difficulty occurring by gelfoam application.