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Scientific Programme
Precongress Course on Oropharyngeal Dysphagia in Stroke Patients
Programme
Thursday 25 October
Partners:
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Auditorium
ESSD
Acadèmia de Ciències Mèdiques de Catalunya i les Balears
Acadèmia de Ciències Mèdiques,Filial del Maresme
Agencia d’Informació, Avaluació I Qualitat en Salut. Observatori de Salut de
Catalunya
CIBERehd and Instituto de Salud Carlos III (Ministry of Health)
Delegació de Salut de l’Ajuntament de Barcelona
Departament de Salut de la Generalitat, Pla General de Malaltia Vascular
Celebral
European Stroke Organization
9.00-9.30 Welcome Presentation Objectives of the Course
President of ESSD, Clavé, Pere
Assistant Director, Centro de Investigación Biomédica en Red en el Área temática
de Enfermedades Hepáticas y DigestivasCIBERehd, Bruix, Jordi
Catalan Pla Director de Malalties Cerebrals Vasculars,Vice President European
Stroke Organization, Chamorro, Àngel
9.30-11.00 Introduction Prevalence of OD in Stroke Patients
1. OD in Stroke patients – prevalence and burden
Smithard, David
2. Screening or initial assessment
a. Dysphagia perspective
Martino, Rosemary
b. Neurological perspective
Dziewas, Rainer
Discussion led by Smithard, David
11.00-11.30 Coffee Break
11.30-13.30 Pathophysiology of OD in stroke patients
a. Neurophysiology of swallowing deficits in stroke patients
Hamdy, Shaheen
b. VFS signs, Impaired swallow response in stroke patients
Clavé, Pere
Discussion led by Ickenstein, Guntram
Consequences of dysphagia in patients with stroke: impact on prognosis
a. Malnutrition and dehydration – Feeding policies in patients with
stroke with reference to the FOOD studies
Smithard, David
b. Aspiration pneumonia in stroke patients
Ickenstein, Guntram
Discussion led by Martino, Rosemary
13.30-14.30 Lunch
14.30-16.00 Treatment of OD in stroke patients
a. Behavioural strategies
Speyer, Renée
b. Pharyngeal electrical stimulation
Hamdy, Shaheen
c. Pharmacological treatment
Rofes, Laia
Discussion led by Dziewas, Rainer and Clavé, Pere
16.00-16.30 Coffee Break
16.30-17.30 Position Statement The basis for a clinical guideline for managing OD
in stroke patients
Smithard, David – UK,
Ickenstein, Guntram – Germany
Hamdy, Shaheen – UK
Chamorro, Angel – Spain, Vice President European Stroke Organization
Martino, Rosemary– Canada
Speyer, Renée– Netherlands
Clavé, Pere – Spain
Laviano, Alessandro– Italy, President of the Educational Committee,
ESPEN
Escarrabill, Joan – Agencia d’Informació, Avaluació I Qualitat en Salut.
Observatori de Salut de Catalunya, AIAQS
Dziewas, Rainer - Germany
Endorsed by CIBERehd, Acadèmia Ciències Mèdiques, AIAQS, ESPEN, European
Stroke Organization
18:30-Welcome Reception
WTC Port Vell
President ESSD Clavé, Pere
Delegada de Salut de l’Ajuntament de Barcelona, Iniesta, Cristina
Congress Programme
Friday 26 October
9:00-11:00 Session 1.Standardization of clinical methods for screening and
assessment of OD (ESSD-DRS)
Chairs: Speyer, Renée and Martino, Rosemary
Auditorium
1. Clinical methods for screening and assessment of OD in adults, ESSD
perspective
Speyer, Renée
2. Clinical methods for screening and assessment of OD in adults, DRS perspective
Martino, Rosemary
Oral presentations
01.01
Standardising the clinical swallow examination: does cervical auscultation valueadd to clinical decision making with dysphagia management?
Bergström, Liza (Sweden); Hartelius, Lena (Sweden); Svensson, Per(Sweden)
01.02 Diagnostic accuracy of the eating assessment tool and the volume-viscosity
swallow test for clinical screening and assessment of oropharyngeal dysphagia
Rofes, Laia (Spain); Arreola, Viridiana (Spain); Mukherjee, Rajat (Switzerland);
Clavé, Pere (Spain)
01.03 Munich dysphagia test – Parkinson's disease (MDT-PD): a new clinical
questionnaire for early assessment of dysphagia in Parkinson's disease
Simons, A. Janine (Germany)
01.04 Assessment of laryngeal movement during swallowing to detect dysphagia in
Parkinson’s disease
Suttrup, Inga (Germany); Hamacher, Christina (Germany); Oelenberg, Stefan
(Germany); Dziewas, Rainer (Germany); Warnecke, Tobias (Germany)
01.05 Development and validation of the Frankfurt dysphagia screening (FRADYSC) for
patients with head and neck cancer after tumor resection: first results
Hey, Christiane (Germany); Lange, Benjamin (Germany); Aere, Christina
(Germany); Eberle, Silvia (Germany); Stoever, Timo (Germany)
Position Statement on Screening and Clinical Assessment Methods; Use of ICD code for
OD
Led by Speyer, Renée and Martino, Rosemary
11:00-11:30 Coffee Break
11:30-13:00 Session 2, Parallel, Dysphagia in children
Chairs: Woisard, Virginie and Roig, Manel
Room A2&3
1. Childhood oromotor disorders: definition, classification, natural history and the
role for oropharyngeal dysphagia
Roig, Manel
2. Evaluationand management of OD in preterm and newborn infants
Woisard, Virginie and Fichaux-Bourin, Pascale
Oral presentations on OD in children
02.01 Clinical and videofluoroscopic characteristics in child post traumatic brain injury
Pinillos, Sergio (Spain); García, Raquel (Spain); Romea, Mayse (Spain); Meavilla,
Silvia (Spain); García, Rut (Spain); Febrer, Anna (Spain); Egea, Natalia (Spain);
Catalan, Natalia (Spain); Milá, Anna (Spain); Varea, Vicente (Spain); García,
Gemma (Spain)
02.02 The relationship between recurrent pneumonia and swallowing disorders
Serel, Selen (Turkey); Demýr, Numan (Turkey); Karaduman, A. Ayþe Turkey)
02.03 Teaching preterm infants to suck and feed: do oral stimulation interventions
make a difference?
Greene, Zelda (Ireland); Walshe, Margaret (Ireland); O'Donnell, Colm PF
(Ireland)
02.04 Development of sucking patterns in preterm infants
da Costa, Saakje (Netherlands)
Position Statement on Dysphagia in Children
Led by Woisard, Virginie and Roig, Manel
11:30-13:00 Session 3, Parallel, Oropharyngeal Dysphagia in Geriatric Patients
Chairs: Kalf, Hanneke and Ekberg, Olle
Auditorium
1. Dysphagia and malnutrition as a geriatric syndrome
Clavé, Pere
2. Drooling and dysphagia in patients with Parkinson’s disease
Kalf, Hanneke
Oral presentations on dysphagia and geriatrics
03.01 Cortical swallowing activation in dysphagic vs. non-dysphagic patients with
Parkinson’s disease
Suntrup, Sonja (Germany); Bejer, Joke (Germany); Suttrup, Inga (Germany);
Teismann, Inga (Germany); Pantev, Christo (Germany); Dziewas, Rainer
(Germany); Warnecke, Tobias (Germany)
03.02 Unexpected epiglottical movements in patients with Parkinsonian syndromes –
endoscopic findings and clinical implications
Luecking, Christoph (Germany); Ceballos-Baumann, Andres (Germany);
Wagner-Sonntag, Edith (Germany)
03.03 Influence of age on the relation between pharyngeal clearance and hyoid
movement duration
Nascimento, Weslania (Brazil); Cassiani, Rachel (Brazil); Santos, Carla (Brazil);
Dantas, Roberto (Brazil)
03.04 Endoscopic pharyngeal pouch stapling - a review of over 300 consecutive cases
in Oxford, UK
Bates, James (United Kingdom); Winters, Stuart (United Kingdom); Potter, Chris
(United Kingdom); Bates, Grant (United Kingdom)
Position Statement on Dysphagia and Geriatrics
Led by Kalf, Hannekeand Ekberg, Olle
13:00-14:30 Lunch
13:30-14:30 Fresenius-Kabi Satellite Symposium
Standardization from Dysphagia Diagnosis to Nutrition
Port Vell
Room A2&3
1. Viscosity of texture modified diets - a new perspective
Hanson, Ben
2. Design of Oral Nutrition Supplements Using Rheological Similarity with Swallow
Barium Test Feed
Gallegos, Crispulo
3. A step-wise concept for diagnosis and management of neurogenic dysphagia
Ickenstein, Guntram
14:30-14.45 Opening Ceremony
President ESSD, Clavé, Pere
President Acadèmia de les Ciències Mèdiques i de la Salut de Catalunya i les Balears,
Net, Àlvar
14.45-16:15 Session 4, Standardization ofDiagnostic methods VFS and FEES
Chairs:Ekberg, Olle and Farneti, Daniele
Auditorium
1. Endoscopic evaluation of swallowing
Schindler, Antonio
2. Videofluoroscopic evaluation of swallowing
Clavé, Pere
Oral presentations
04.01 A comparison of approaches for measuring functional tongue-pressure reserve
Steele, Catriona (Canada)
04.02 The reliability of the MASA dysphagia screening protocol compared to fees for
patients in an acute stroke unit
Vanderwegen, Jan (Belgium); Van Nuffelen, Gwen (Belgium); Guns, Cindy
(Belgium); De Bodt, Marc (Belgium)
04.03 Fees to improve swallowing restoration following transoral robotic surgery supraglottic laryngectomy (TORS-SL)
Lawson, Georges (Belgium); Mendelsohn, Abie (United States); Remacle, Marc
(Belgium); Rijckaert , Myriam (Belgium); Degrelle, Isabelle (Belgium); Delacroix,
Laurence (Belgium); Devuyst, Vinciane (Belgium); Bachy, Vincent (Belgium)
04.04 Non-radiological measurement of extent and duration of upper esophageal
sphincter (UES) opening during swallowing using Endoflip
Regan, Julie (Ireland); Walshe, Margaret (Ireland); Rommel, Nathalie (Belgium);
Tack, Jan (Belgium); McMahon, Barry (Ireland)
04.05 Pharyngeal phase kinematics in dysphagic stroke patients with monohemispheric
lesions: a manoendoscopic evaluation
Ledl, Christian (Germany); Knerr, Ylva (Germany); Bader, Peter (Germany)
Position Statement on Standardization of Diagnostic Methods, VFS and FEES
Led by Ekberg, Olle and Farneti, Daniele
16:15-16:45 Coffee Break
Port Vell
16:45-18:30 Session 5. Nutritional Complications of OD
Auditorium
Chairs: Burgos, Rosa and Laviano, Alessandro
1. Nutritional screening/assessment in patients with OD
Laviano, Alessandro
2. Dysphagia and malnutrition: from screening to nutritional treatment
Burgos, Rosa
Oral presentations
05.01 Feeding route (s) of hospitalized patients in need for phonoaudiological
evaluation
Mancopes, Renata (Brazil); Mulazani Maria, Camila (Brazil); Trindade Gonçalves,
Bruna Francieli (Brazil); Fávero, Talita (Brazil)
05.02 Determining the prevalence and reasons for medication swallowing difficulties in
the general population
Cichero, Julie (Australia); Radhakrishnan, Chandramouli (Australia); Raidhan,
Aisha (United Kingdom); Smyth, Heather (Australia); Nissen, Lisa (Australia);
Steadman, Kathryn (Australia)
05.03 Malnutrition as a complication of oropharyngeal dysphagia in specific clinical
situations
Carrión , Silvia (Spain); Roca, Maria (Spain); Ortega, Omar (Spain); Arreola,
Viridiana (Spain); Clavé, Pere (Spain)
05.04 Superior preference for a range of ready-to-drink pre-thickened ONS among
clinicians treating dysphagia patients
Kaspar, Kala (Switzerland); Herentrey, Klaus (Switzerland); Pradon, Emmanuel
(Switzerland)
05.05 Effect of human saliva on the consistency of a newly developed moderately thick
oral nutritional supplement for patients with dysphagia
Sliwinski, Edward (Netherlands); Vallons, Katleen (Netherlands); Oudhuis,
Lizette (Netherlands)
Position Statement on Nutritional Complications of OD
Discussion led by Laviano, AlessandroandBurgos, Rosa
Day 2. Saturday October 27
9.00-11.00 Session 6, Parallel, Respiratory complications of OD
Chairs: Verin, Eric and Almirall, Jordi
Auditorium
1. Breathing and swallowing coordination in patients with dysphagia
Cichero, Julie
2. Pathophysiology of aspiration pneumonia
Almirall, Jordi
3. Oral health in patients with OD
Nart, Josep
Oral presentations
06.02 The association between post-swallow residue and aspiration on the next
swallow
Molfenter, Sonja (Canada); Steele, Catriona (Canada)
06.03 Aspiration risk in dysphagia patients older than 75 years. A retrospective study
at a Swiss University Hospital, 2008-2011
Duan, Jingming (Switzerland); Castiglioni, Kristina (Switzerland); Bohlender,
Joerg (Switzerland)
06.04 Oropharyngeal dysphagia in patients with obstructive sleep apnea syndrome
Mozzanica, Francesco (Italy); Schindler, Antonio (Italy); Atac, Murat (Italy);
Monzani, Anna (Italy); Ceriani, Eleonora (Italy); Ottaviani, Francesco (Italy);
Schindler, Antonio (Italy); Atac, Murat (Italy); Sonzini, Giulia (Italy); Ginocchio,
Daniela (Italy); Ottaviani, Francesco (Italy)
06.05 Pneumonia during neurorehabilitation: randomized trial of the swallowing
assessment approaches: facial oral tract therapy vs. fiberoptic endoscopic
evaluation of swallowing
Kjaersgaard, Annette (Denmark); Nielsen, Lars Hedemann (Denmark); Sjölund,
Bengt (Denmark)
06.06 Implementation of a swallowing test in a hospital reduces pneumonia mortality
and readmission for pneumonia
Sagalés, Maria (Spain); Cocho, Dolores (Spain); Soler, Núria (Spain); Homs,
Isabel (Spain); Cobo, Marivi (Spain); Bao, Pilar (Spain); Pou, Marina (Spain);
Mas, Pilar (Spain); Serra, Jordi (Spain.
Position Statement on Respiratory Complications in OD
Led by Verin, Eric and Almirall, Jordi
9:00-10:00 Session 7, Parallel, Education: Master’s in Dysphagia
Chairs:Denk-Linnert, Doris-Maria and Cabrera, Esther
Room A2&3
1.
The Bologna Declaration: a framework for educational activities in dysphagia and
their professional implications
Cabrera, Esther
2.
TrinityCollegeP.Grad Diploma Clinical Speech and Language Studies (Dysphagia)
Walshe, Margaret
3.
University of Toulouse Master in Dysphagia
Woisard, Virginie
4.
TurinUniversity Master in Deglutition.
Schindler, Antonio
10:00-11:00 Session 8, Parallel, Best posters presented as mini orals 1
Chairs: Wagner-Sonntag, Edith and Pokieser, Peter
Room A2&3
Mini orals: 08.01 to 08.10
11:00-11:30 Coffee Break
Port Vell
11:30-13:00 Session 9, Parallel, Clinical relevance of OD in specific clinical
situationsChairs: Denk-Linnert, Doris-Maria and Kynigou, Maria
Auditorium
1. Dysphagia in patients with lesions of recurrent nerves and head and neck cancer
Quer, Miquel
2. OD in neurodegenerative diseases
Walshe, Margaret
Oral presentations
09.01 Tongue base strength changes contribute to postlaryngectomy dysphagia
Printza , Athanasia (Greece); Pavlidou, Elena (Greece); Triaridis, Stefanos
(Greece); Constantinidis, Jiannis (Greece)
09.02 Clinical consistency in tracheostomy management among speech & language
therapists in Repubic of Ireland
Downes, Susan (Ireland); Curran, Aongus (Ireland); Walshe, Margaret (Ireland)
09.03 Dysphagia after tracheal and laryngotracheal resection
Rechenmacher-Strauß, Julia (Austria); Hoetzenecker, Konrad (Austria); Klepetko,
Walter (Austria); Bigenzahn, Wolfgang (Austria); Denk-Linnert, Doris-Maria
(Austria)
09.04 Pathophysiology of swallowing in dysphagic patients with dystrophia myotonica
Type 1: a systematic review.
Pilz, Walmari (Netherlands); Baijens, Laura (Netherlands)
Position Statements on OD in H&N cancer and in Neurodegenerative Diseases
Led by Denk-Linnert, Doris-Maria and Kynigou, Maria
11:30-12:30 Session 10, Parallel, Best posters presented as mini orals 2
Chairs: Lawson, Georges and Dagdilelis, Lukas
Room A2&3
Mini orals: 10.01 to 10.10
12:30-13:00 Session 11, Parallel, Clinical questionnaire for OD
Chair:TBD
Room A2 &3
1. How to make a clinical session/questions with patients with OD
Pokieser, Peter
13:00-14:30 Lunch
13.30-14.30 Poster viewing
Port Vell
Room A1&Foyer
14:30-16:00 Session 12. Behavioural treatments and rehabilitation
Chairs: Baijens, Laura and Bülow, Margareta
Auditorium
1. Classic rehabilitation strategies
Speyer, Renée
2. New neurostimulationmanagementstrategies
Dziewas, Rainer
Oral presentations
12.01 Bilateral modulation of functional cortical swallowing activity and
neurotransmitters concentrations after paired associative brain stimulation: a
FMRI and magnetic resonance spectroscopy (MRS) study
Michou, Emilia (United Kingdom); Mistry, Satish (United Kingdom); Vidyasagar,
Rishma (United Kingdom); Downey, Darragh (United Kingdom); Williams, Steve
(United Kingdom); Hamdy, Shaheen (United Kingdom)
12.02 Tongue pressure production against hard palate during supraglottic swallow and
super supraglottic swallow
Fujiwara, Shigehiro (Japan); Ono, Takahiro (Japan); Tamine, Kenichi (Japan);
Fujiu-Kurachi, Masako (Japan); Hori, Kazuhiro (Japan); Maeda, Yoshinobu
(Japan); Sara, Boroumand (Switzerland); Ina, Nitschke (Switzerland); Vith,
Ursula (Switzerland); Bohlender, Joerg (Switzerland)
12.03 withdrawn
12.04 Metronome therapy to treat dysphagia in patients with Parkinson's disease
Nozaki, Sonoko (Japan); Matsui, Toshihiro (Japan); Yoshikawa, Hiroo (Japan);
Kaneto, Taizo (Japan); Domen , Kazuhisa (Japan); Daimon, Takashi (Japan)
12.05 Neuromuscular electrical stimulation for the treatment of oropharyngeal
dysphagia
Jaume Bauza, Gabriel (Spain); Rodriguez-Villalba, Rosana (Spain)
Position Statement on Behavioural Treatments andRehabilitation
Led byBaijens, Laura and Bülow, Margareta
16.00-16.30 Coffee Break
Port Vell
16.30-18.00 Session 13. Treatment 2: Dietary management, looking for a
consensus Chairs:Cichero, Julie and Clavé, Pere
Auditorium
1. Adaptation of Fluids and Solids, an Australian perspective
Cichero, Julie
2. Adaptation of Fluids and Solids, a UK perspective
Norrie, Roslyn
3. International terminology and definitions for texture modified foods and liquids.
Lam, Peter
Oral presentations
13.01 Bolus rheology and tongue pressure: the two important factors of bolus
swallowing
Chen, Jianshe (United Kingdom); Alsanei, Woroud (United Kingdom)
13.02 A numerical analysis of the extensional flow through the pharynx
Ascanio, Gabriel (Germany); Salinas, Martin (Mexico); Brito-de la Fuente,
Edmundo (Germany); Gallegos, Crispulo (Germany); Vicente, William (Mexico);
Marquez, Jorge (Mexico)
13.03 Therapeutic effect of xanthan gum-based thickener on swallowing function in
patients with oropharyngeal dysphagia
Rofes, Laia (Spain); Arreola, Viridiana (Spain); Mukherjee, Rajat (Switzerland);
Clavé, Pere (Spain)
13.04 Carbonated liquids as a compensatory strategy for people with dysphagia poststroke
Tegou, Georgia (Ireland); Sdravou, Katerina (Greece); Dagdilelis, Lukas
(Greece); Walshe, Margaret (Ireland)
Position Statement on Dietary Management, Looking for a Consensus
Led by Cichero, Julie and Clavé, Pere
18.00 Closing Ceremony
Auditorium
Abstract Book
Oral Presentations
01.01
Standardising the clinical swallow examination: does cervical auscultation
value-add to clinical decision making with dysphagia management?
Bergström, Liza1; Hartelius, Lena2; Svensson, Per3
1
University of Gothenburg, Sahlgrenska Academy at University of Gothenburg,
Sweden; 2University of Gothengurg, Sahlgrenska, Sweden; 3Helsingborg Hospital,
Drottninggatan, Sweden
Introduction: This study investigates the validity and reliability of cervical auscultation
(CA) as part of the clinical swallow examination (CSE). Clinical judgements for
dysphagia management were assessed under two CA conditions; (1) CA-only, using
isolated swallow-sound clips, (2) CSE+CA, using extra clinical swallow examination
information such as patient case history, oromotor assessment and the same swallowsound clips as condition one. These were compared against a fibreoptic endoscopic
evaluation of swallowing (FEES) reference test. Materials: 18 swallow samples compiled
from 12 adult patients were assessed via FEES. Patients’ swallow sounds were
simultaneously recorded using a Littmann E3200 electronic stethoscope and saved
as .mpg files. Methods: The two CA swallow samples were sent to 13 experienced
dysphagia clinicians recruited from the UK and Australia. Samples were rated in terms
of (1) if dysphagic, (2) if the patient was safe on consistency trialled, and (3) dysphagia
severity. Results: Sensitivity measures ranged from 83-95%, specificity measures
ranged from 50-92% across the conditions. Intra-rater agreement ranged from 69-97%
total agreement. Inter-rater reliability for dysphagia severity rating showed substantial
agreement. Discussion: The validity (sensitivity and specificity) and rater reliability for
CA conditions in this study are comparable to and often better than other wellestablished CSE components. This study suggests that CA value-adds to clinical
dysphagia assessment and management.
01.02
Diagnostic accuracy of the eating assessment tool and the volume-viscosity
swallow test for clinical screening and assessment of oropharyngeal
dysphagia
Rofes, Laia1; Arreola, Viridiana2; Mukherjee, Rajat3; Clavé, Pere1
1
CIBERehd - Hospital de Mataró, Mataró, Spain; 2Hospital de Mataró, Mataró,
Spain; 3Nestec Ltd, Lausanne, Switzerland
Introduction: We aimed to determine the diagnostic accuracy of the Eating Assessment
Tool (EAT-10) and the volume-viscosity swallow test (V-VST) for oropharyngeal
dysphagia (OD). Material and Methods: We studied 120 patients with swallowing
difficulties and 14 healthy subjects. OD was clinically evaluated by a 10-item
questionnaire (EAT-10) and a bedside method (V-VST). Scoring ≥3 in the EAT-10 is
considered abnormal. The V-VST consisted of the administration of 5-20 mL liquid
boluses at nectar (1.2g/100 mL water), thin (water) and extreme spoon-thick (6g/100
mL
water)
viscosities
obtained
with
a
xanthan
gum-based
thickener(Resource®ThickenUpClear, Nestlé Health Science). The V-VST was
considered positive for OD when one or more of the following signs were present: cough,
fall in oxygen saturation ≥3%, voice changes (impaired safety); piecemeal deglutition
or residue (impaired efficacy). Videofluoroscopy was the reference standard for OD
diagnosis by using the same viscosities. Diagnostic accuracy was assessed by the AUC
of the ROC curve and sensitivity and specificity values. Results: Prevalence of OD was
94% and that of aspirations 19% according to the videofluoroscopic study. The EAT-10
showed a ROC AUC of 0.88 for OD and a sensitivity and specificity of 79% and 87% for
EAT-10 ≥3. The V-VST presented 94% sensitivity and 87% specificity for OD, 86%
sensitivity and 79% specificity for impaired safety, 91% sensitivity and 28% specificity
for aspirations, and 78% sensitivity and 74% specificity for impaired efficacy.
Discussion: Clinical methods for screening (EAT-10) and assessment (V-VST) of OD
offer high diagnostic accuracy. We recommend their universal application to improve
the nutritional management of older and neurological patients at risk for OD.
01.03
Munich dysphagia test – parkinson's disease (mdt-pd): a new clinical
questionnaire for early assessment of dysphagia in parkinson's disease
Simons, A. Janine
Schön Klinik München Schwabing, München, Germany
Dysphagia as a negative prognostic predictor for the remaining lifetime in Parkinsonism
is generally recognized too late and treated usually at onset of massive deglutition
problems with health impairment. A 26-item patient questionnaire for early prognosis of
dysphagia in Parkinson’s disease (PD) was developed for the study involving 82 PD
patients. Comparison parameters were applied and severity scales within two
standardized diagnostics created: Clinical examination focused on structure, sensory
reflexes, functions, swallowing tests and instrumental diagnosis as a Parkinson’sspecific adaptation of the FEES®-protocol (functional parameters, posterior bolus
leakage, pharyngeal residues, saliva accumulation, laryngeal penetration/aspiration). In
both diagnostics (on-drug-state) the nutrition ingestion was assessed with liquid, solid
and dry consistencies (daily relevant measures) and two pills. The MDT-PD fulfills all
test quality criteria. The discrimination quality of the weighted MDT-PD sum score for
dysphagia classification, determined via ROC analysis, results in a) not noticeable vs.
noticeable a sensitivity of 82% with a specificity of 71% and b) not noticeable vs. risk of
aspiration a sensitivity of 90% with a specificity of 86% with similar results in the cross
validation. A strong correlation between criteria sum score and weighted MDT-PD sum
score was observed (r=+0.699, p<0.001) with high internal consistency (CronbachsAlpha: 0.913) in the MDT-PD questionnaire. Doctors and therapists are presented with a
valid, reliable and applicable screening tool for preventive dysphagia risk estimation as
well as dysphagia graduation for PD-patients. The web application www.mdtparkinson.de shall facilitate the implementation of the MDT-PD into daily clinical routine.
01.04
Assesment of laryngeal movement during swallowing to detect dysphagia in
parkinson’s disease
Suttrup, Inga; Hamacher, Christina; Oelenberg, Stefan; Dziewas, Rainer; Warnecke,
Tobias
Department of Neurology, University of Münster, Münster, Germany
Introduction: Oropharyngeal dysphagia is a common and disabling symptom in
Parkinson’s disease (PD). Neurological examination and clinical swallowing tests do not
sufficiently predict swallowing dysfunction in PD. Therefore, we evaluated a novel tool
for this purpose, i. e. assessment of laryngeal movement (LM) during swallowing.
Methods: Swallowing function of twenty-two consecutive PD patients (16 male, 6
female; mean age 70.5 years; mean Hoehn and Yahr stage 3.05) was assessed by 50ml
water swallowing test and fiberoptic endoscopic evaluation of swallowing (FEES). In
addition, a standardized clinical examination of LM was performed containing the
parameters initiation, range of motion, velocity, plateau phase and overall rating. Using
FEES as gold standard, statistical measures for ability to detect dysphagia were
calculated for LM assessment and 50ml water swallowing test. Results: The incidence of
endoscopically proven dysphagia was 77.3%. Aspiration events were found in 22.7% of
patients. According to the endoscopic dysphagia severity score swallowing dysfunction
was classified as being mild in 12, moderate in 3 and severe in 2 patients. In
comparison to FEES sensitivity of LM assessment and the 50ml water swallowing test
was 82% and 24% respectively. All false-negative results of LM assessment occurred in
patients with mild dysphagia characterized by vallecular residues of solid food
consistencies. Conclusion: Standardized assessment of LM is a suitable method to
evaluate Parkinsonian dysphagia. In particular, it may help to clinically identify PD
patients that show impaired swallowing dysfunction, but do not yet aspirate. Key words:
Parkinson’s disease, swallowing, FEES, dysphagia, laryngeal movement.
01.05
Development and validation of the frankfurt dysphagia screening (fradysc) for
patients with head and neck cancer after tumor resection first results
Hey, Christiane1; Lange, Benjamin2; Aere, Christina1; Eberle, Silvia1; Prof. Dr. Stoever,
Timo3
1
Department of Phoniatrics and Pediatric Audiology, Frankfurt/Main,
Germany; 2Department of Medical Psychology and Medical Sociology, Goettingen,
Germany; 3Dept. of ORL, Frankfurt/Main, Germany
Introduction Dysphagia is a frequent implication of head and neck cancer (HNC)
patients. To date, there is no sufficient screening for swallowing disorders of those
patients. Aim of this study is the development and validation of a screening to detect
therapy relevant dysphagia of HNC patients after tumor resection. Material and Methods
The dysphagia screening FraDySc consists of an oromotor testing with a defined water
swallow test. FraDySc independently, is tested twice by two therapists followed by a
fiberoptic endoscopig evaluation of swallowing (FEES) Langmore-Standard. Since
November 2010, 55 HNC patients (Stage II - IV) after tumor resection were
documented. Exclusion criteria were a preknown swallowing disorder or neurological
diseases. So far, the interraterreliability and the accordance of the Pass/Fail results of
FraDySc and FEES were determined. Results Up to date the interraterreliability
regarding the FraDySc is optimal (Cohen’s α = 1.00, p < .001) and the concordance of
FraDySc and FEES excellent. (Cronbach’s α = .949). Discussion The first results of this
study promise FraDySc as a very good tool for a valid and time efficient identification of
patients with a therapy relevant swallowing disorder and therefor the need for an early
rehabilitation after tumor resection.
02.01
Clinical and videofluoroscopic characteristics in children post traumatic brain
injury
Pinillos, Sergio1; García, Raquel1; Romea, Mayse2; Meavilla, Silvia1; García, Rut1; Febrer,
Anna1; Egea, Natalia1; Catalan, Natalia1; Milá, Anna1; Varea, Vicente1; García, Gemma1
1
Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain; 2Fundación Atención
Temprana, Zaragoza, Spain
Introduction. Traumatic brain injury (TBI) is the most common acquired cause of
neurological disability in childhood. Improving medical management has increased
survival. Oropharyngeal dysphagia is common in these patients. Material and methods.
Retrospective study of children admitted with severe TBI (Glasgow less than 9) from
January 2009 to February 2011. Clinical and videofluoroscopic characteristics income
and evolution have been collected Results. 11 patients, mean age 14 years and 6
months.7 males. Mean admission Glasgow 7. Drainage of intracranial injury was needed
in, focal parenchymal lesions in 6. Average 10 days of mechanical ventilation. Average
day stay in PICU 21. Average days on nasogastric tube 42. Initial videofluoroscopy
(mean day 34): altered (penetration - aspiration airway and pharyngeal residue) in 81%
(n = 9, severe = 1, moderate = 4, mild = 6). Initial oral-motor impaired exploration in
9 patients: hypomotility jaw, labial and lingual, oral and pharyngeal residue. Thickeners
were required initially in 6 patients, and adapted diet in 9. Oral-motor rehabilitation
program in 6. Average hospital stay 56 days. Normalized early videofluoroscopy in 6
and oral-motor alterations were normal in 10 patients after 12 weeks of income.
Conclusions. Incidence of oropharyngeal dysphagia in severe TBI is high (90%), mostly
mild or moderate. Progression is parallel to the neurological outcome, with an early
resolution in most cases. Dysphagia is often for solids and liquids, and both efficacy and
safety are affected. Management requires an adaptation of diet and oral-motor
rehabilitation.
02.02
The relationship between recurrent pneumonia and swallowing disorders
Serel, Selen; Demýr, Numan; Karaduman, A. AyÞe
Hacettepe University, Ankara, Turkey
INTRODUCTION: This study aimed to determine the relationship between recurrent
pneumonia and swallowing disorders.MATERIAL AND METHODS: 274 pediatric patients
who admitted to our clinic with swallowing difficulties in the last 6 months were
included.Clinical information was noted.Oral, pharyngeal and esophageal swallowing
physiologies were examined with videofluoroscopic swallowing study.RESULTS: The
study included 274 patients whose median age was 20 months(min:1,
max:244).Median height was 75 cm(min: 49, max: 178) and median weight was 9
kg(min:2, max:53).83,2% of the patients were cerebral palsied children,5,5% were
syndromic children,3,6% were muscular dystrophy,2,2% were Down’s syndrome and
5,5% were others.67,9%(n:186) of patients had recurrent pneumonia.As a result of
swallowing assessment,66,4% of patients had oral phase disability,32,5 had penetration
and 46,4% had aspiration.45,3% of patients showed esophageal motility disorders
symptoms and 35,8% of them showed reflux sypmtoms.We suggested nonoral feeding
to 45,3%(n:124) of patients.There is no correlation between oral phase disability and
recurrent pneumonia(p>0,05).There is statistically significant correlation between
aspiration and recurrent pneumonia(p<0,001,r:0,49),esophageal motility disorders and
recurrent pneumonia(p<0,05,r:0,19) and also between reflux and recurrent
pneumonia(p<0,001, r:0,22).There is statistically significant difference in recurrent
pneumonia in patients with and without reflux(p<0,001) and also patients with and
without esophageal motility disorders(p<0,05).DISCUSSION: We concluded that not
only pharyngeal swallowing disorders like aspiration but also esophageal disorders and
reflux can result in recurrent pneumonia.So it should be considered in swallowing
evaluation.
02.03
Teaching preterm infants to suck and feed: do oral stimulation interventions
make a difference?
Greene, Zelda1; Walshe, Margaret2; O'Donnell, Colm PF3
1
Our Lady's Children's Hospital, Dublin, Ireland; 2Trinity College, Dublin,
Ireland; 3National Maternity Hospital, Dublin, Ireland
INTRODUCTION Preterm infants (< 37 weeks gestation) are surviving in greater
numbers and many present with difficulties in oral feeding progression. A range of oral
stimulation interventions are reported which aim to facilitate nutritive sucking for oral
feeding. Outcomes include accelerated weaning from tube feeding, enhanced sucking
maturation, greater weight gain and fewer days of hospitalization. This systematic
review aims to (1) examine the efficacy and safety of oral stimulation interventions on
oral feeding in preterm infants; (2) provide the best available evidence to inform clinical
practice; (3) assist with research planning. MATERIALS & METHODS Search included
Cochrane Central Register of Controlled Trials (CENTRAL); Medline EMBASE; CINAHL;
ERIC; Psych INFO; Web of Science; Web of Knowledge; AMED; SCOPUS; Dissertation
Abstracts were searched from inception to May 2012. Published and unpublished trials
in any language were included with no date restrictions. Clinical trials web sites were
searched for ongoing clinical trials. Relevant journals and conference proceeding
abstracts were hand searched. Only randomised controlled trials (RCTs) and quasirandomised controlled trials were included. One author retrieved full texts of reports
and all three authors examined final full texts and extracted data. RESULTS: The search
yielded 4,474 titles. Screening of titles identified 66 trials for further scrutiny. 24
studies were eligible for inclusion in the review. In the included studies there was
considerable heterogeneity. Risk of bias was high. Methodological flaws are associated
with all studies. DISCUSSION The best available evidence on the efficacy and safety of
these interventions will be discussed and directions for future research will be provided
02.04
Development of sucking patterns in preterm infants
da Costa, Saakje
Hanze University Groningen, Groningen, Netherlands
Introduction: Preterm infants often have problems learning to suckle at the breast or to
drink from a bottle. It is unclear whether this is due to their preterm birth or whether it
is the consequence of neurological damage. Knowledge about the development of
sucking patterns in preterm infants and the ability to recognise the risk factors and
indicators of abnormalities in this development will provide paediatricians and nurses
insight in how they could best set up oral feeding schedules. Methods and materials:
We studied the development of sucking patterns in preterm infants from the time the
infant stated feeding orally until the age of ten weeks post-term. At weekly, or twoweekly intervals we observed sucking, swallowing and respiration with the aid of the
Neonatal Oral-Motor Assessment Scale (NOMAS). Results: The development of sucking
patterns in preterms differs from that of healthy, fullterm infants: three quarters of the
preterms developed a normal sucking pattern later than fullterm infants did. In
particular, the developmental course of sucking is different in preterms with intrauterine
growth retardation and preterms with a BPD. These two groups, as well as the group of
very preterm infants (< 28 weeks’ PMA) require extra attention when oral feeding
schedules are set up. Discussion: It is important, therefore, to check carefully whether
a preterm infant is ready to start feeding orally. When oral feeding actually commences,
it is important to monitor carefully whether the infant keeps in control of its
physiological parameters and recovers rapidly after a feed. In the care of preterm
infants, close collaboration between all people involved, is of vital importance. The care
of preterm infants requires close collaboration between all people involved.
03.01
Cortical swallowing activation in dysphagic vs. Non-dysphagic patients with
parkinson’s disease
Suntrup, Sonja1; Bejer, Joke1; Suttrup, Inga2; Teismann, Inga2; Pantev, Christo3;
Dziewas, Rainer2; Warnecke, Tobias2
1
Institute for Biomagnetism and Biosignalanalysis /Department of Neurology, University
of Muenster, Muenster, Germany; 2Department of Neurology, University of Muenster,
Muenster, Germany; 3Institute for Biomagnetism and Biosignalanalysis, University of
Muenster, Muenster, Germany
Introduction: Whereas cortical compensation of dysphagia has been shown in stroke,
this topic has not been addressed in Parkinson’s disease (PD). The aim of our study was
to determine the different patterns of cortical swallowing processing in PD patients with
and without dysphagia. Methods: We measured brain activity using whole-head
magnetoencephalography (MEG) in 20 patients with PD (10 with and 10 without
manifest dysphagia) and an age-matched control group of 10 healthy subjects.
Swallowing function was assessed using FEES, a 150 ml water swallowing test and two
swallowing questionnaires (SDQ, SWAL-QUOL). Subjects performed an established selfpaced swallowing paradigm during the MEG measurement. Data were analyzed by
means of synthetic aperture magnetometry and group analyses were performed using a
permutation test. Results: As compared to healthy subjects, all PD patients showed a
reduction in cortical swallowing activation which was even stronger in patients with
manifest dysphagia (Fig.1). Comparing the two patient groups, those without manifest
dysphagia showed significantly stronger activation in more lateral parts of the (pre)motor cortex(p<0.01). Discussion: In PD not only brain stem and basal ganglia circuits,
but also cortical areas modulate swallowing function in a clinically relevant way.
According to recent literature on PD there is a switch from the use of defective striatomesial frontal towards relatively intact parietal-lateral premotor circuits to facilitate
movement performance. Thus increased activation of the lateral premotor cortex in
non-dysphagic patients may be a compensatory mechanism that preserves swallowing
function. When PD progresses and increasingly affects cortical areas including this
compensatory pathway dysphagia becomes manifest.
03.02
Unexpected epiglottical movements in patients with parkinsonian syndromes –
endoscopic findings and clinical implications
Luecking, Christoph1; Ceballos-Baumann, Andres2; Wagner-Sonntag, Edith1
1
Schoen Klinik Muenchen Schwabing, Munich, Germany; 2Schoen-Klinik MuenchenSchwabing, Munich, Germany
Introduction: Dysphagia is a common symptom in the course of Parkinsonian
syndromes. In atypical parkinsonism (PSP, MSA) swallowing problems occur earlier and
usually are more severe than in idiopathic Parkinson’s Disease. As part of the
pharyngeal phase, so far mainly deficient epiglottic tilt has been described. Material and
Methods: Flexible endoscopic evaluation of swallowing (FEES) was used to evaluate the
deglutition in patients with idiopathic Parkinson’s Disease and different forms of atypical
parkinsonism. Special focus was put on abnormal epiglottical movements. Results: We
obeserved 25 patients with prolonged epiglottic closure (up to 5 seconds). In addition,
some of these patients showed epiglottic tremor, freezing (inability to swallow for up to
10 seconds) or repeated, short-lasting, spontaneous downfolding of the epiglottis
independent of swallowing (“floppy epiglottis”). Similar changes were observed in some
stroke patients with basal ganglia involvement, especially bilateral, but not in other
conditions. The most prominent video examples will be shown and discussed.
Discussion: To our knowledge these findings have not been reported yet. The
prolongued epiglottical closure might be a reason for the dyspnoea experienced by the
patients while swallowing and has to be distinguished from aspiration. The
pathophysiology of these findings is not yet fully understood. Possible explanations
might be the combination of muscle rigidity, bradykinesia and discoordinated
swallowing movements, due to pathology in the brainstem-basal ganglia network.
03.03
Influence of age on the relation between pharyngeal clearance and hyoid
movement duration
Nascimento, Weslania; Cassiani, Rachel; Santos, Carla; Dantas, Roberto
University of São Paulo, São Paulo, Brazil
Introduction: Pharyngeal clearance is related to the upper esophageal sphincter opening.
The hyoid movement has an important participation in this opening. For a safe swallow,
hyoid movement duration should be longer than pharyngeal clearance. The objective of
this investigation was to evaluate the influence of age on the relation between
pharyngeal clearance duration and hyoid movement duration. Methods: The swallowing
of 55 normal volunteers, 31 men and 24 women, divided into a younger group (19-55
years, mean 36 years, n=33) and an older group (56-77 years, mean 65 years, n=22)
was evaluated by the videofluoroscopic method. Each volunteer swallowed in duplicate
5 mL and 10 mL of a highly viscous liquid bolus (100% barium sulfate, viscosity 701.4
cp, density 1.8 g/mL). We measured the duration of pharyngeal clearance, the duration
of hyoid movement, and the relation between pharyngeal clearance duration and hyoid
movement duration. Results: The pharyngeal clearance duration and the hyoid
movement duration were longer in younger than older subjects. The difference between
younger and older subjects was significant in men but not in women. There was no
difference between groups in the relation between pharyngeal clearance duration and
hyoid movement duration. Discussion: Older subjects have shorter duration of
pharyngeal clearance and shorter duration of the hyoid movement than younger
subjects, mainly among men, but the relationship between pharyngeal clearance and
hyoid movement duration is the same as in younger subjects. The results suggested
that the ageing process does not alter the coordination between pharyngeal clearance
and hyoid movement.
03.04
Endoscopic pharyngeal pouch stapling - a review of over 300 consecutive
cases in oxford, uk
Bates, James1; Winters, Stuart1; Potter, Chris2; Bates, Grant1
1
John Radcliffe, Hospital Oxford, Oxford, United Kingdom; 2South Devon Healthcare,
Torquay, United Kingdom
Bates J, Winter S, Potter C, Bates G. Introduction: Pharyngeal diverticulum is a cause of
cervical dysphagia. It predominantly affects patients over 50 years of age, with an
estimated incidence in the west of 1/100 000. While surgery is usually the treatment
the type of operation is controversial. This study reviews all endoscopic pharyngeal
pouch stapling operations completed by a single surgeon between 1992-2011. Methods:
A retrospective review of all patients undergoning an endoscopic pharyngeal pouch
stapling procedure between 1992 and 2011. Data was collected including previous
surgical intervention, co-morbidities, pouch size, complications, recurrence and
outcome. Results: 320 patients who underwent pharyngeal pouch stapling were
identified. All patients underwent the procedure by the senior author of this study. The
age range was 46 - 96, average 88. At follow-up there was a subjective success rate of
88%, with a mean length of stay of 2.2 days. 14% of patients had reoccurrence of
symptoms sufficient for repeat surgical intervention. There were seven cases of dental
injury, one perforation and one post-operative hemorrhage , no deaths. Discussion:
Pharyngeal pouch surgery is a controversial topic, with endoscopic pharyngeal pouch
surgery recommended in the NICE guidelines in 2003. To date no large retrospective
study has been able to give an accurate recurrence rate for pouch stapling. Our study
indicates a recurrence rate in 14% of patients. This review shows the technique has a
high success rate with low rsiks.
04.01
A comparison of approaches for measuring functional tongue-pressure
reserve
Steele, Catriona
Toronto Rehabilitation Institute - University Health Network, Toronto, Canada
Introduction: Tongue-palate pressure is a parameter of considerable interest in the
field of dysphagia. Maximum isometric tongue-palate pressures (MIPs) declines in
healthy aging and in dysphagia. Functional reserve (FR) is the difference between MIPs
and swallowing pressures. Reduced FR is thought to constitute a risk for developing
functional swallowing impairments. We compare different approaches for calculating FR
and recommend an optimal, standardized approach.
Materials and Methods: Tongue-palate pressure data were collected from 78 healthy
adults (40 < age 40; 38 > 60) during anterior and posterior MIPs, regular (RESS) and
effortful (ESS) saliva swallows and water swallows (4 repetitions per task). Six different
measures of reserve were calculated using maximum anterior MIPs or maximum ESS
pressures at the top, and mean or maximum RESS or water swallow pressures at the
bottom of the range, respectively. Correlations with age and maximum anterior MIPs
were explored to confirm suitability for measuring FR. The impact of normalization to
maximum MIP range was explored.
Results: All six equations for calculating FR displayed significant correlations with age
(R: -0.23 to -0.41) and with maximum anterior MIP (R: 0.28 to 0.90), confirming
sensitivity to age- and strength-related changes in tongue-pressure capacity.
Normalization eliminated correlations with age for all anterior MIP referenced equations.
Discussion: Functional tongue-pressure reserve can be derived using a variety of
different parameters. The simplest method is to calculate the difference between
maximum anterior MIPs and mean RESS pressures. Declines in FR reflect changes in
tongue strength, independent of age considerations.
04.02
The reliability of the masa dysphagia screening protocol compared to fees for
patients in an acute stroke unit
Vanderwegen, Jan1; Van Nuffelen, Gwen2; Guns, Cindy2; De Bodt, Marc2
1
CHU Saint-Pierre, Brussels, Belgium; 2Antwerp University Hospital, Antwerp, Belgium
Introduction Early and correct identification of dysphagia in acute stroke patients may
prevent deleterious consequences on health and survival. This study assessed the
reliability of the Dutch translation of the MASA protocol to correctly identify dysphagia
and aspiration in stroke patients when compared to FEES. Methods During 6 months, 84
first ever stroke patients were evaluated. Each patient was assessed within 36 hours of
admittance with both MASA and FEES. The speech pathologists and otolaryngologist
were blinded to each other’s findings. The previously established cut-off scores for
dysphagia and aspiration on the published MASA protocol were respected. Dysphagia
during FEES was considered present when either significant stasis of secretions at rest,
premature spillage (>2 seconds), penetration or a considerable amount of residue was
visualized. Aspiration during FEES was defined as aspiration of any amount of food
during any stage of swallowing and scored according to the PAS-score. Results 100
assessments were made in 84 patients. The prevalence of dysphagia was 73% (MASA)
and 68% (FEES). The prevalence of aspiration was 65% (MASA) and 43% (FEES).
Sensitivity (Se) of the MASA for dysphagia was 96% while specificity (Sp) was 75%;
the positive predictive value (PPV) was 89% and the negative predictive value (NPV)
was 90%. The results of the assessment for detection of aspiration were Se = 87%, Sp
= 51%, PPV = 57%, NPV = 85%. Discussion The MASA is a valid assessment tool
compared with FEES when evaluating acute stroke patients, resulting in both good
sensitivity and specificity for the bedside identification of dysphagia and aspiration.
04.03
Fees to improve swallowing restoration following transoral robotic surgery supraglottic laryngectomy (tors-sl)
LAWSON, Georges1; Mendelsohn, Abie2; Remacle, Marc1; Rijckaert, Myriam1; Degrelle,
Isabelle1; Delacroix, Laurence1; Devuyst, Vinciane1; Bachy, Vincent1
1
Université Catholique de Louvain CHU de Mont Godinne, Yvoir, Belgium; 2David Geffen
School of Medicine at UCLA, Los Angeles, United States
INTRODUCTION: TORS is a minimally invasive technique. It ensures more precise
operation compared to the classic transoral procedure, the objective of this study is to
describe swallow function rehabilitation and patient’s outcomes following TORS-SL.
MATERIALS & METHODS:Patient records receiving TORS-SL for squamous cell
carcinoma (SCC) with at least 6-months follow-up fit inclusion for this study.
Postoperative swallow function is assessed starting on postoperative day one with
fiberoptic endoscopic evaluation of swallowing (FEES). Patients without aspiration on
FEES are then referred for modified barium swallow study (MBSS). With the
demonstration of safe swallow on both modalities allows for safe advancement of oral
diet to solids with thickened liquids followed by thin liquids. FEES & MBSS are use to
identified the swallowing impairment process and to select the position, bolus
consistence, timing for a safe swallowing process training. RESULTS: 18 patients (14
male, 4 female) were included in the study having a mean follow-up time of 21.2
months (SD=12.3). Overall, patients required between 2–29 days for return of safe
swallow for solids (median=4.5, SD=9.41). Patients required between 2–45 days for
return of safe swallow for thin liquids (median=5.5, SD=14.9). Female gender,
advanced pathologic T-stage (III/IV), simultaneous neck dissection, and temporary
postoperative vocal fold hypomobility all led to significant delays in return of swallow
function (p<0.01). CONCLUSION: FEES & MBSS use to identified the swallowing
impairment process and to select rehabilitation program improve the quality of care in
the context of minimally invasive surgery. Larger studies are encouraged.
04.04
Non-radiological measurement of extent and duration of upper esophageal
sphincter (ues) opening during swallowing using endoflip
Regan, Julie1; Walshe, Margaret1; Rommel, Nathalie2; Tack, Jan2; McMahon, Barry1
1
Trinity College Dublin, Dublin, Ireland; 2Neurogastroenterology & Motility Clinic,
University Hospital Leuven, Leuven, Belgium
Introduction: Objective measurement of UES opening based on videofluoroscopy and
manometry can challenge dysphagia clinicians. We sought to measure extent and
duration of UES opening during swallowing events in healthy subjects using a novel
distensibility tool. Methods: Fourteen healthy subjects (20-50 years) were recruited.
The FLIP was passed orally and the balloon on the distal end of the probe was
positioned across the UES. At a 12ml balloon volume, subjects completed two dry
swallows and two 5ml and 10ml liquid swallows. Data from the second dry, 5ml and
10ml liquid swallow was used to analyse extent (mm) and duration (ms) of UES
opening and drop in intra-balloon pressure (mmHg) during swallowing. Results:
Thirteen of fourteen subjects completed the study protocol. During dry swallows,
baseline UES diameter (median 4.89mm; IQR 4.875-4.9) increased to 9.55mm (IQR
8.835-10.125) (p<.001) and intra-balloon pressure (18.84mmHg; IQR 16.81-19.45)
dropped to 3.6mmHg (IQR 1.665-5.81) (p=0.002). During 5ml liquid swallowing, UES
diameter increased from 4.89 to 8.61mm (IQR 7.25-9.9) (p<.001) and pressure
dropped to 4.75mmHg (IQR 1.565-7.13) (p<0.001). During 10ml liquid swallows,
diameter increased from 4.89 to 8.27mm (IQR 7.34-8.96) (p<.001) and pressure
dropped to 2.96mmHg (p<0.001). Median duration of UES opening was 0.5 seconds
across dry (IQR 0.35-0.65), 5ml (IQR 0.35-0.60) and 10ml (IQR 0.45-0.50) liquid
swallows. FLIP measures of UES diameter and intra-balloon pressure changes during
swallowing are presented in colour contour plots (see schema). Conclusions:
Quantitative data derived from FLIP regarding extent and duration of UES opening
during swallowing provides novel and clinical valuable information both from a
diagnostic and intervention viewpoint.
04.05
Pharyngeal phase kinematics in dysphagic stroke patients with
monohemispheric lesions: a manoendoscopic evaluation
Ledl, Christian; Knerr, Ylva; Bader, Peter
Schoen Klinik Bad Aibling, Bad Aibling, Germany
Introduction: Unilateral lesions of dominant (sub-)cortical areas have been shown to
cause oropharyngeal dysphagia and to affect pharyngeal motor performance. This study
aims to describe changes in pharyngeal phase after unilateral hemispheric stroke by
comparing pharyngo-esophageal pressure generation and its timing in normals versus
dysphagic patients. Method: Manometric data of fifteen tracheotomized dysphagic
patients after unilateral hemispheric stroke were compared to normative data of age
and gender matched controls. Subjects swallowed 10 times 5ml boli (pudding).
Maximum pressure generation in the oro- and hypopharynx, onset and duration of
pressure, as well as onset and amplitude of upper esophageal sphincter relaxation were
recorded. Results: Pressure amplitudes in the oro- and hypopharynx (66.1 mmHg,
p<=0.000; 80.7mmHg, p<=0.000) were reduced in dysphagic patients. Pressure
reduction was correlated with an increased duration of pressure generation (p=<0.000).
UES relaxation took place 2 msec before the onset of oropharyngeal pressure which was
followed by the onset of hypopharyngeal pressure with a delay of 7 msec. Resting
pressure of the UES was lower when compared to normals (p=<0.000), duration of
relaxation was prolonged (0.97 sec.; p=<0.000). Discussion: The effectiveness of the
pharyngeal wave in dysphagic patients is impaired by diminished pharyngeal pressure
and by anticipated onset of lower pharyngeal pressure. Reductions in pressure tend to
be compensated by prolonged pressure durations. Timing differences point to a
structural change in swallowing after supratentorial lesions and therefore to a
(sub)cortical involvement in pharyngeal phase motor control. These results have to be
validated in a greater population.
05.01
Feeding route (s) of hospitalized patients in need for phonoaudiological
evaluation
Mancopes, Renata; Mulazani Maria, Camila; Trindade Gonçalves, Bruna Francieli;
Fávero, Talita
Universidade Federal de Santa Maria, Santa Maria, Brazil
Introduction: Facing the impossibility of oral intake (OI), an alternative feeding route
(AFR) is indicated. Objectives: To characterize the feeding route used by hospitalized
patients in need of phonoaudiological evaluation of the swallowing in a university
hospital. Methods: Consults to the database of the Laboratory of Dysphagia in the
hospital, we selected the data on feeding routes at the time of first evaluation in bed, as
measured by speech therapists. The AFRs were classified as short term (nasogastric /
nasoenteral tubes) or long term (gastrostomy / jejunostomy). For data analysis, the
frequency of each route was described by means of descriptive statistics. Results: Total
of 113 patients, 61.06% of those fed exclusively by short term AFR, 24.78% orally only,
7.08% by long term AFR only, 4.42% orally supplemented by long-term AFR and 2.66%
orally supplemented by a short term AFR. Discussion: 60.01% were fed exclusively on
short term AFRs, which should not be used for more than four weeks. In such cases the
action involves strategies to increase oral intake to remove the probe, or indication of
long term AFRs in non-safe OI cases. For patients with exclusively oral feeding
(24.72%), the evaluation of swallowing serves to verify the need to restrict
consistencies. In the cases with the exclusive use of long term AFRs (7.08%), it is
defined the possibility of reusing the OI, as well as the time and consistencies used for
transition. With patients who are fed orally supplemented by AFR (2.66% and 4.42%)
the conditions of oral feeding are evaluated and it is decided which route should be
considered main or supplementary. Conclusions: Most hospitalized patients in need of
phonoaudiological evaluation of swallowing used AFRs, mainly short term only.
05.02
Determining the prevalence and reasons for medication swallowing difficulties
in the general population
Cichero, Julie1; Radhakrishnan, Chandramouli1; Raidhan, Aisha2; Smyth, Heather3;
Nissen, Lisa1; Steadman, Kathryn1
1
School of Pharmacy, The University of Queensland, Brisbane, Australia; 2Kings College
London, Brisbane, United Kingdom; 3Queensland Alliance for Agriculture and Food
Innovation, The University of Queensland, Brisbane, Australia
INTRODUCTION: Difficulties with swallowing solid dosage forms is a common problem
among patients who are classified as dysphagic. These patients or their carers modify
their medications by crushing tablets and opening capsules, and mixing the powder with
various food-based items. Dosage form modification similar to this also occurs amongst
people who can swallow food but who find it difficult to swallow whole tablets and
capsules. This project investigated the issues around medication swallowing in nondysphagic people. METHODS: 153 Healthy volunteers completed a survey that included
food-related questions around food textures, memory of choking incidents, and
willingness to try new foods; and medication-related questions around regularity of
medication use, and memory of choking or swallowing problems. The person’s gag
reflex, taste receptor density and chewing efficiency were then assessed. Finally, the
person was observed while swallowing a capsule. RESULTS: 33% reported difficulties
swallowing whole tablets/capsules. 19% titled their head back to swallow pills. Although
26% recalled a choking incident related to food or medicine, this was unrelated to tablet
swallowing issues. 75% of participants used too little water to swallow medication.
Tongue size relative to oral cavity size was a factor in pill swallowing issues.
DISCUSSION: This pilot study has determined that many otherwise healthy people find
whole tablets and capsules difficult to swallow. Tilting the head back while swallowing
was worryingly a common approach to swallowing medications. This poses a risk for
aspiration of medication. Insufficient water taken with medications may contribute to
oesophageal injury, due to delayed transit.
05.03
Malnutrition as a complication of oropharyngeal dysphagia in specific clinical
situations
Carrión, Silvia; Roca, Maria; Ortega, Omar; Arreola, Viridiana; Clavé, Pere
Hospital de Mataró, Mataró, Spain
Introduction: Malnutrition is one of the major complications of oropharyngeal dysphagia
(OD) but little is known about the characteristics of malnutrition in specific clinical
settings. Aim: To compare the nutritional and hydration status of elderly patients with
chronic OD and patients with OD and acute complications (pneumonia) Materials and
Methods: 3 groups of elderly patients (>70 years) with OD according to the volume
viscosity swallow test (V-VST) were studied with an elderly control group without OD
(Group D). Group A, with history of aspiration pneumonia (AP); Group B, without AP
history and Group C with acute pneumonia. Screening for malnutrition was performed
with the Mini Nutritional Assessment test (MNA®) and assessment with anthropometric
characteristics and body composition with bioimpedance (BIA 101). Biochemical
markers of malnutrition were also collected. Results: 59 patients were studied, 15
patients in each group (Group C, n=14). The group of patient with acute pneumonia
presented: a) higher rates of malnutrition according to the MNA (21.4%) (Group A,
13.3%; Group B, 6.7%; Group D, 0% (p> 0.05)); b) lower albumin and cholesterol
levels (p < 0.001) and higher PCR (p< 0.001); c) lower BMI (25.4 kg/m2) (p=0.01); d)
a reduction in basal metabolism (p=0.04), in muscle mass (p=0.06) and in fat mass
(p=0.05) and e) a reduction in intracellular water (p = 0.04). Discussion: Patients with
OD are at risk for malnutrition, which is increased in acute conditions such as
pneumonia. Screening for malnutrition should be performed on all patients with OD,
particularly during an acute infection.
05.04
Superior preference for a range of ready-to-drink pre-thickened ons among
clinicians treating dysphagia patients
Kaspar, Kala; Herentrey, Klaus; Pradon, Emmanuel
Nestlé Health Science, Vevey, Switzerland
INTRODUCTION: Guidelines recommend use of oral nutritional supplements (ONS) in
patients at risk of undernutrition based on Grade A evidence. Diet modification is also
an evidence-based intervention integral to dysphagia patient management. Prethickened ONS are designed to help a multidisciplinary team of healthcare professionals
(HCPs) address the comprehensive needs of dysphagia patients at risk of malnutrition.
The objective of this study was to assess the preferences for and performance
characteristics of various pre-thickened ONS. MATERIALS AND METHODS: A study was
conducted comparing a new range of specially-designed pre-thickened ONS (Resource®
ThickenUp HP/HC Semi-Liquid & Semi-Solid, Nestlé) [A] with comparable ranges
(Nutilis® Complete & Fortimel Crème, Nutricia) [B], and (Fresubin Thickened Stage 1 &
Fresubin® Crème, Fresenius Kabi) [C]. For each evaluation, vanilla ONS was presented
to HCPs in an unbranded, randomized manner. RESULTS: Multidisciplinary HCPs (n=90;
60 speech-language therapists and 30 dietitians) reported significant overall preference
for ONS range A. By direct comparison, 62% preferred A, 21% preferred B, and 17%
had no favorite; while 68% preferred A, 22% preferred C, and 10% had no favorite. 8
out of 10 HCPs rated ONS range A well-suited for patients’ day-to-day consumption as
well as swallowing rehabilitation. DISCUSSION: HCPs who treat dysphagia patients
judged ONS range A superior to comparable products. Preference for ONS range A was
linked to specific sensory attributes in terms of taste and consistency.
05.05
Effect of human saliva on the consistency of a newly developed moderately
thick oral nutritional supplement for patients with dysphagia
Sliwinski, Edward1; Vallons, Katleen2; Oudhuis, Lizette2
1
Danone Research, Centre for Specialised Nutrition, Wageningen, Netherlands; 2TNO
Food and Nutrition, Zeist, Netherlands
Introduction: Starch-based thickeners (ST) are commonly used to modify the
consistency of foods /drinks for patients with dysphagia. These thickeners are highly
sensitive to breakdown by Ą-amylase in saliva, leading to a thin and potentially unsafe
fluid consistency. The effect of saliva on the consistency of a pre-thickened £\-amylaseresistant Oral Nutritional Supplement (ONS) (AR) was studied. Materials and Methods:
AR product: moderately thick ONS (Nutilis Complete from Nutricia N.V., Zoetermeer,
The Netherlands). Control: tap water thickened with standard ST. In vitro test: One ml
of human saliva was added to 100g (pre-)thickened product. After 10 and 50 min the
amount of decantable liquid was determined. Consistency change was determined by
measuring the uniaxial compression force with a SMS TA-XT2i Texture Analyser. Human
testing: Healthy adults took ~30ml of test product and moved the tongue at ~1
rotation/s. After 10s the bolus was spat into a canister, and viscosity measurement was
started directly. Viscosity was determined in a rotational viscometer, Rapid Visco
Analyser (RVA) at a speed of 160 rpm. Results: For AR hardly any decantable liquid was
formed, while for ST it varied between 19 and 39 ml (p<0.001), which corresponds to
4-8 boluses of 5 ml. For AR the compression force hardly changed, while for ST it
decreased with 23 to 48% (p<0.001). Human testing showed that remaining viscosities
(in %) for AR (30s: 72%; 60s: 70%) were significantly (p<0.0005) higher compared to
those found for ST (30s: 16%; 60s: 11%). Conclusions: In the presence of saliva the
consistency of the AR product was retained better than water thickened with ST. We
hypothesize that foods/drinks with amylase-resistance are preferred due to the stability
of its viscosity during consumption.
06.01
The association between post-swallow residue and aspiration on the next
swallow
Molfenter, Sonja; Steele, Catriona
Toronto Rehabilitation Institute, Toronto, Canada
Introduction: Post-swallow residue is widely accepted as a sign of swallowing
impairment and is assumed to pose risk for aspiration on subsequent swallows. This
study investigates the link between post-swallow residue and penetration-aspiration (PA)
on the immediately-occurring subsequent swallow.
Materials & Methods: 130 thin-liquid single bolus videofluoroscopic swallowing clips
from patients with neurogenic dysphagia were selected for study because they
displayed multiple swallows per bolus. Residue for each sub-swallow (N=618) was
analyzed using the Normalized Residue Ratio Scale, an image-based, anatomicallyreferenced measurement method for vallecular (NRRSv) and piriform sinus (NRRSp)
residue. NRRS scores ≥ 0.06 aligned with clinician judgments of moderate or severe
residue. Safety was rated using the Penetration-Aspiration Scale, with scores of ≥ 3
reflecting impaired swallowing safety. The association between moderate/severe
residue presence at the end of a swallow and safety on the next swallow was examined.
Results: Post-swallow residue in one or both pharyngeal spaces was significantly
associated with PA (χ2=5.091, df=1, p =0.024). However, when analyzed separately by
residue location, only vallecular residue was significantly predictive of PA (χ2=15.029,
df=1, p=0.000). The distribution of NRRSv scores by PA showed an NRRSv cut-point of
0.09 between safe and unsafe swallows, with 2.07 times greater risk of PA above this
value.
Discussion: Post-swallow vallecular residue, measured with an anatomically-referenced
and normalized ratio scale, is significantly associated with PA on subsequent swallows.
A clinically meaningful cut-point of 0.09 on the NRRSv scale demarcates PA risk. Further
research with residue for different consistencies is needed.
06.02
Aspiration risk in dysphagia patients older than 75 years: a retrospective study
at a swiss university hospital, 2008-2011
Duan, Jingming1; Castiglioni, Kristina2; Bohlender, Joerg2
1
Department of Phoniatrics and Logopedics University Hospital Zurich, Zürich,
Switzerland; 2Department of Phoniatrics and Logopedics University Hospital Zurich,
8091 Zurich, Switzerland
Introduction: There has been little data reported about aspiration risk in elderly
dysphagia patients. We analyzed the etiological distributions of dysphagia patients older
than 75 years and explored their relationships with aspiration. Material and
Methods: A retrospective chart review was performed for dysphagia patients older than
75 years seen at the Department of Phoniatrics and Logopedics at the University
Hospital Zurich between October 2008 and November 2011. Results: Out of the 2158
patients seen in the clinic over this period, 312 (15%) of them suffered from dysphagia.
Within this dysphagia group 71 (23%) patients were older than 75 years. The most
frequent etiology within the elderly group was neurological problems with the incidence
of 42%, followed by presbyphagia (31%) and structural problems (27%). Aspiration
was detected in 45% of patients older than 75 years. The incidence of aspiration
differed between the etiological groups: neurogenic dysphagia 57%, structural
dysphagia 50% and presbyphagia 23%. Discussion: 45% of our dysphagia patients
older than 75 years suffered from aspiration, which may indicate aspiration to be an
important consideration during the treatment and management of elderly dysphagia
patients. Although aspiration was more frequently observed in neurogenic and
structural dysphagia patients, its incidence in presbyphagia patients was also high, up
to 23%. Therefore more attention may need to be paid to the examination and
treatment of aspiration in presbyphagia patients than previously thought.
06.03
Oropharyngeal dysphagia in patients with obstructive sleep apnea syndrome
Mozzanica, Francesco1; Schindler, Antonio1; Atac, Murat1; Monzani, Anna1; Ceriani,
Eleonora1; Ottaviani, Francesco2; Schindler, Antonio1; Atac, Murat1; Sonzini, Giulia1;
Ginocchio, Daniela1; Ottaviani, Francesco2
1
L. Sacco Hospital, Milan, Milan, Italy; 2San Giuseppe Hospital, Milan, Italy
Introduction: obstructive sleep apnea syndrome (OSAS) is a highly prevalent sleep
disorder. Patients with OSAS are likely to exhibit an impaired swallowing reflex. The aim
of the study is to assess the prevalence and characterics of oropharyngeal dysphagia in
patients affected by OSAS. Materials and Methods: 72 patients with OSAS, 54 men and
18 women, with a mean age of 60.1 ± 11.1 years were enrolled. Each patient
underwent a fiberoptic evaluation of swallowing (FEES). In order to assess dysphagia
severity the pooling score (PS), the penetration aspiration scale (PAS), and the
Dysphagia outcome and severity scale (DOSS) were used. Finally each patient managed
to complete autonomously the SWAL-QOL questionnaire. Results: PAS, PS and DOSS
scores were pathological in 28, 34, 32 patients respectively. Piecemeal deglutition was
demonstrated in 46 patients, while 50 patients demonstrated a delayed swallowing
reflex. The SWAL-QOL scored lower than 80/100 in the Fatigue and Sleep subscales,
higher in all other subscales. A correlation between age and presence of dysphagia was
found. The mean AHI score was 38.7 ± 19.3. The cohort of patients was divided in two
groups: 30 patients with 15 < AHI < 29 and 42 patients with AHI > 30. No significant
differences were found between the two groups of patients in both FEES and SWAL-QOL
scores. Discussion: mild sign of dysphagia are found in patients with OSAS. The risk
increase with age while no correlations has been demonstrated with OSAS severity.
06.04
Pneumonia during neurorehabiliation: randomized trial of the swallowing
assessment approaches: facial oral tract therapy vs. Fiberoptic endoscopic
evaluation of swallowing
Kjaersgaard, Annette1; Nielsen, Lars Hedemann2; Sjölund, Bengt H.3
1
The Region Hospital Hammel Neurocenter and The Institute of Public Health, University
of Southern Denmark, Odense, Denmark, Hammel, Denmark; 2Region Hospital Hammel
Neurocenter, Hammel, Denmark; 3The Institute of Public Health, University of Southern
Denmark, Odense, Denmark, Odense, Denmark
A randomized controlled clinical trial of two methods to assess the ability for oral intake
conducted between June 2009 and April 2011 at a specialized national
neurorehabilitation center. Adult patients with acquired brain injury (ABI) were
randomly assigned to receive either standard clinical assessment, Facial-Oral Tract
Therapy (F.O.T.T.) or Fiberoptic Endoscopic Evaluation of Swallowing (FEES) as a guide
for initiation of oral intake. Assessments were repeated until oral intake could be
initiated. The aim was to examine whether the risk of developing pneumonia during
rehabilitation was greater for patients assessed by F.O.T.T. than for patients assessed
by FEES. The primary outcome measure was number of pneumonias developed during
the rehabilitation period (mean 74 days). 119 patients were included in the analysis of
primary outcome (62 from F.O.T.T. and 57 from FEES). Main reasons for dropouts were
‘being lost to follow-up’ or ‘discontinued intervention’. Five patients could not participate
in the FEES assessment because of cognitive difficulties. There were no significant
injury-related or demographic differences between groups. Four patients from F.O.T.T.
and 12 from FEES were diagnosed with pneumonia (p=0.03). Excluding six patients
with pneumonia before initiating oral intake left 10 patients with pneumonia. Five out of
10 patients developed pneumonia within 10 days after initiating oral intake (one in
F.O.T.T. and four in FEES). A holistic clinical approach like F.O.T.T. to assess swallowing
disorders in patients with ABI is at least as effective to identify a suitable time for
initiating oral intake as an organ-based, impairment-related, instrumental approach like
FEES.
06.05
Implementation of a swallowing test in a hospital reduces pneumonia
mortality and readmission for pneumonia
Sagalés, Maria1; Cocho, Dolores2; Soler, Núria3; Homs, Isabel4; Cobo, Marivi5; Bao,
Pilar6; Pou, Marina7; Mas, Pilar3; Serra, Jordi4; on behalf of Dysphagia Working Group1
1
Hospital General de Granollers, Granollers, Spain; 2Department of
Neurology;3Pharmacy Department; 4Department of Otorhinolaryngology; 5Department
of Speech Therapy; 6Department of Geriatrics; 7Department of Rehabilitation
INTRODUCTION Dysphagia increases the risk of aspiration pneumonia, especially high
in elderly and in neurologic patients. The aim of the study was to evaluate the health
benefits of dysphagia screening test implementation in a hospital in terms of aspiration
pneumonia and mortality. METHODS: Observational retrospective study. We included all
patients with pneumonia diagnosis in two different periods, before the application of a
protocol created by a multidisciplinary working dysphagia group (march 2009-2010 :
G2009) and after (march 2011-2012 : G 2011) the implementation of a dysphagia
screening test ( 2 volumes/ 3 textures, 2v/3T) in the hospital. We studied dysphagia
detection, hospital readmissions, and deads reported. RESULTS We analized 896
patients hospitalized for pneumonia, (451 patients in G2009 and 445 in G2011), 57%
were men, mean age 64± 28 years. A significant increase of patients diagnosed with
dysphagia was detected and treated (43% vs. 62%, p=0,001) and a reduction in
pneumonia readmission was observed (5% vs. 2,7%, p=0,004). Dysphagia was
detected in 316 patients, 71 of them died, 62% of those who died were pneumonia
patients with dysphagia not treated ( mostly broncoaspiration pneumonia admitted
patients) and 38% pneumonia patients diagnosed and treated for dysphagia (p=0,003).
CONCLUSION The implementation of swallowing test in a community hospital increases
early detection of dysphagia allowing treatment, reduces pneumonia mortality in
dysphagia treated patients and readmissions for pneumonia.
09.01
Tongue base strength changes contribute to postlaryngectomy dysphagia
Printza, Athanasia1; Pavlidou, Elena2; Triaridis, Stefanos3; Constantinidis, Jiannis2
1
2nd Ent Dept, Medical School, Aristotle University of Thessaloniki, Thessaloniki,
Greece; 22nd Ent Dept, Medical School, Aristotle University, Thessaloniki, Greece; 31st
Ent Dept, Medical School, Aristotle University, Thessaloniki, Greece
Introduction. Swallowing changes following laryngectomy. Many patients experience
difficulties with solid foods and a feeling of pharyngeal food residue. Postlaryngectomy
anatomic changes affect tongue base retraction due to weakness or decreased range of
motion. Higher tongue base to posterior pharyngeal wall pressures are required to
propel food through the pharynx. The aim of this study was to measure tongue strength
and endurance in postlaryngectomy patients who did not self-report dysphagia.
Materials and methods. A cohort of consecutive patients who had completed
definitive treatment at least 4 months ago participated to the study. The control group
consisted of healthy, age matched participants. All participants provided a series of
tongue strength measurements obtained via a pressure sensor: at the tip of the tongue,
at the middle, at the base of tongue static and during normal swallowing and forceful
swallowing. They were also measured exercising half of their maximum pressure each
one for as long as possible (tip, middle and base of tongue) providing a measure of the
tongue
endurance.
Results. For all measurements smaller mean values and bigger range of values were
recorded for the postlaryngectomy group. Statistical significance was noted only for
strength and endurance at the base of tongue. During forceful swallowing the mean
groups
values
were
comparable.
Discussion. Total laryngectomy compromises swallowing via changes of the tongue
contribution to pharyngeal food propagation related to diminished tongue base strength.
Swallowing exercises aimed at maximizing tongue base retraction can help patients
overcome these changes.
09.02
Clinical consistency in tracheostomy management among speech & lang
therapists in rep ireland
Downes, Susan1; Curran, Prof Aongus2; Walshe, Dr Margaret3
1
Trinity College Dublin, Ireland, dublin, Ireland; 2Professor of Oto-Rhino-Laryngology, St
Vincent's University Hospital, Elm Park, Dublin 4, Ireland; 3Trinity College Dublin, Dublin,
Ireland
INTRODUCTION There is significant variability in how speech and language therapists
(SLTs) manage people with tracheostomies internationally. Many countries including the
Republic of Ireland have no guidelines on the skills and knowledge base required by
SLTs working with people with tracheostomy. There is limited research on the practice
patterns of SLTs in this area to guide the development of these guidelines. The aim of
this research is to examine practice patterns among SLTs who manage swallowing and
communication in adults and children with tracheostomies in the Republic of Ireland
(ROI). MATERIALS/METHODS An online survey was sent to all SLTs in ROI working with
children and adults with tracheostomies. The survey was adapted from Ward et al
(2007) for Australian SLTs. The questions explored demographics, training, clinical roles
and responsibilities, dysphagia management and decannulation procedures. A total of
84 participants completed the survey, RESULTS Similar to Ward et al (2007) findings in
Australia, there is a wide variation in clinical practice, training and the perceived role of
the SLT in the management of people with tracheostomies. Only half the respondents
had completed a formal tracheostomy competency programme and many felt under
confident in working in this area. DISCUSSION This research supports the need for
mandatory competency programmes to be introduced to SLTs working in ROI. The
results may not be specific to ROI as other countries also lack guidelines. SLTs
emphasised the need for on-going training and supervision. The implications of the
findings are discussed.
09.03
Dysphagia after tracheal and laryngotracheal resection
Rechenmacher-Strauß, Julia1; Hoetzenecker, Konrad2; Klepetko, Walter2; Bigenzahn,
Wolfgang1; Denk-Linnert, Doris-Maria1
1
Department of Otorhinolaryngology, Division of Phoniatrics-Logopedics, Medical
University of Vienna, Austria, Vienna, Austria; 2Department of Surgery, Division of
Thoracic Surgery, Medical University of Vienna, Austria, Vienna, Austria
Introduction
Subglottic airway obstruction can be caused by prolonged tracheal intubation or
tracheostomy, inflammatory diseases (especially Wegener´s granulomatosis) and
malignant infiltration of larynx or trachea.The evaluation of the specific outcome of
airway surgery of subglottic obstructions mainly focuses on airway restoration and
respiratory function. However, the effect of the surgical interventions used to expand
the airway may also impact upon the laryngeal function of airway protection during
swallowing and swallowing function as such.
Materials and Methods
In this pilot-study patients with subglottic airway obstruction were included in a
prospective protocol. Swallowing function was assessed with FEES preoperatively and 25 days postoperatively.
Results
From December 2011 to March 2012 8 patients underwent tracheal or laryngotracheal
resection. The length of resection ranged between 1.5 cm and 5 cm (median 2.8 cm).
Preoperatively 7 of the 8 patients treated had a normal swallowing function. The 2
patients with the longest resections (4 and 5 cm resp.) showed postoperatively a severe
dysphagia with delayed triggering of the swallow reflex, reduced laryngeal elevation,
residues in the hypopharynx, laryngeal penetration and aspiration during the swallow.
Therefore tube-feeding was necessary and functional swallowing therapy was performed.
The patients returned to full oral intake diet about 30 days postoperatively.
Discussion
The results of the study underline the importance of swallowing evaluation following
laryngotracheal resections. FEES proved to be the appropriate diagnostic tool to
evaluate the patient’s swallowing function and ability to protect the airway. The length
of resection seems to be a risk factor for developing a severe dysphagia after surgery.
09.04
Pathophysiology of swallowing in dysphagic patients with dystrophia
myotonica type 1: a systematic review.
Pilz, Walmari; Baijens, Laura
Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University
Medical Center, Maastricht, Netherlands
Introduction. This systematic review explores the studies on diagnostic examinations for
swallowing disorders in patients with dystrophia myotonica type 1. Material and method.
Two authors, independently, carried out the literature search using the electronic
biomedical literature databases Embase, PubMed, and The Cochrane Library. The search
was limited to English, German, French, Spanish, Portuguese or Dutch language
publications. MeSH and Thesaurus terms were used. Free-text words (truncation or
wildcards) were used for the period after September 2010 till January 2012. Also hand
searching reference lists was performed. To determine the level of evidence of the
included articles, the ABC rating scale of Siwek et al. was used. Results. Sixteen studies
were included. Discussion. The body of literature on pathophysiology of swallowing in
dysphagic patients with dystrophia myotonica type 1 remains very limited. The
conclusions of most studies can not be compared to one another because of
heterogeneous designs and outcome measures. Almost all studies show methodological
problems. Further research on diagnostic examinations for swallowing disorders in
patients with dystrophia myotonica type is recommended.
12.01
Bilateral modulation of functional cortical swallowing activity and
neurotransmitters concetrations after paired associative brain stimulation: a
fmri and magnetic resonance spectroscopy (mrs) study.
Michou, Emilia; Mistry, Satish; Vidyasagar, Rishma; Downey, Darragh; Williams, Steve;
Hamdy, Shaheen
The University of Manchester, Manchester, United Kingdom
Purpose:Combined pharyngeal electrical and transcranial magnetic stimulation or paired
associative stimulation (PAS) is a novel neurostimulation technique shown to induce
beneficial neurophysiological and behavioural effects on swallowing in health and
dysphagic stroke patients (Michou et al, Gastroenterology 2012). Here we present first
in man data for invivo GABA mediated brain changes in neural activation after PAS
assessed by fMRI and MRS.
Methods:Healthy adults (n=11, 38±9 yoa) were randomised to receive real and sham
PAS on 2 separate visits after which fMRI were performed to assess changes in brain
activations in response to water and saliva swallowing and during rest, performed in a
randomised order. Data were analysed (SPM8) at P<.001. MRS data were acquired
before and after fMRI with PAS as the intervention on both visits and GABA
concentrations were measured (AMARES, jMRUI).
Results:Following real PAS, group analyses of ‘water swallowing-rest’ and
‘salivaswallowing-rest’ showed different levels of increased activation in motor and
premotor areas bilaterally. Following real PAS and after the fMRI tasks, GABA
concentrations decreased significantly ipsilateral to PAS (P=.008) and were significantly
lower in the motor cortex contralateral to PAS (P=.013).
Conclusion:Targetted PAS applied to the human pharyngeal motor cortex induces
localand remote changes in both primary and non-primary areas for water and saliva
tasks. Moreover, PAS promotes a reduction in the concentration of inhibitory
neurotransmitter, GABA, following performing active behavioural swallowing tasks.
These findings provide novel evidence for a GABAergic mechanism underlying the
beneficial effects of PAS on the swallowing brain network.
12.02
Tongue pressure production against hard palate during supraglottic swallow
and super supraglottic swallow
Fujiwara, Shigehiro1; Ono, Takahiro1; Tamine, Kenichi1; Fujiu-Kurachi, Masako2; Hori,
Kazuhiro3; Maeda, Yoshinobu1; Sara, Boroumand4; Ina, Nitschke4; Vith, Ursula5;
Bohlender, Joerg5
1
Dept. of Prosthodontics, Gerodontology and Oral Rehabilitation, Osaka Univ. Grad. Sch.
of Dent., Suita, Japan; 2Niigata University of Rehabilitation, Graduate School of
Rehabilitation, Murakami, Japan; 3Division of Dysphagia Rehabilitation, Niigata Univ.
Grad. Sch. of Med. and Dent. Sciences, Niigata, Japan; 4Clinic for Geriatric and Special
Care Dentistry, University of Zurich, Zurich, Switzerland; 5Department of Oto-RhinoLaryngology, Division of Phoniatry, University Hospital Zurich, Zurich, Switzerland
Introduction: Supraglottic swallow (SS) and super supraglottic swallow (SSS) are
voluntary airway protection techniques which are widely used in the rehabilitation of
patients with dysphagia. Although there have been some reports about the effect of
these techniques on the pharyngeal stage of swallowing, little is known about that on
the oral stage. The purpose of this study is to investigate the influence of SS and SSS
on the state of tongue-palate contact by measuring tongue pressure production against
hard palate.
Materials and Methods: Nineteen healthy adults (six males and thirteen females,
average age; 25.9 years) participated in this study. Tongue pressure during swallowing
5 ml water with normal swallow, SS and SSS was measured by using an ultra-thin
tongue pressure sensor sheet with 5 pressure-sensing points attached to the hard
palate. Maximal magnitude, duration and integrated value of tongue pressure were
analyzed based on the tongue pressure waveform obtained. 
Results and Discussion: Maximal magnitude and integrated values during SS were
higher at posterior part of the hard palate than those during normal swallow, and those
during SSS were higher at each part of the hard palate than those during normal
swallow. In addition, those during SSS were higher at anterior-median part and
posterior circumferential part of the hard palate than those during SS. These results
suggest that SS and SSS facilitated tongue-palate contact which might improve bolus
driving force in the oral stage. SSS was more effective than SS in this respect.
12.04
Metronome therapy to treat dysphagia in patients with parkinson's disease
Nozaki, Sonoko1; Matsui, Toshihiro2; Yoshikawa, Hiroo3; Kaneto, Taizo4; Domen,
Kazuhisa3; Daimon, Takashi3
1
Hyogo University of Health Science, Kobe, Japan; 2Takasago Municipal Hospital,
Takasago, Japan; 3Hyogo College of Medicine, Nishinomiya, Japan; 4Tottori Medical
Center, Tottori, Japan
Introduction: We conducted a 6-week crossover study in patients with PD to determine
whether a treatment process involving a metronome would improve their swallowing
function. Material and Methods: Twenty patients with PD were randomly and equally
assigned to one of two groups. Group 1 (n = 10) was assigned treatment M(-), which
involved cervical stretching, lingual exercise, and deglutition of jelly for 2 weeks. This
was followed by a 2-week, therapy-free interval, and then treatment M(+), which
involved cervical stretching, lingual exercise, and deglutition of jelly with a metronome
for 2 weeks. The metronome treatment required patients to swallow 5 mg of jelly on
the sixth beat. Group 2 (n = 10) followed the same treatment in the reverse sequence:
M(+), followed by a therapy-free interval, and then treatment M(-), each for 2 weeks.
The primary outcome was the change in duration of oral transit, pharyngeal transit, and
stage transit, and the amount of residue in the pharynx as evaluated by
videofluoroscopic examination of swallowing. The analysis was performed using linear
mixed-effects models with outcomes, period, treatment, and carryover as fixed effects,
and the patient as a random effect. Results: Oral transit time was significantly
shortened after treatment M(+) (median: 0.60 sec) compared with treatment M(-)
(median: 0.78 sec) , P=0.02. The residual amount of jelly in the vallecula after
deglutition tended to decrease more after treatment M(+) compared with treatment M(), P = 0.06. Discussion: The audio and visual stimuli provided by the metronome
established the rhythm of the swallowing movement of the tongue. The sound of the
sixth beat served as the cue to swallow. This may be the reason why this treatment was
effective.
12.05
Neuromuscular electrical stimulation for the treatment of oropharyngeal
dysphagia
Jaume Bauza, Gabriel; Rodriguez-Villalba, Rosana
Hospital Son Espases, Palma de Mallorca, Spain
Introduction: Dysphagia is a common disorder among patients attending our ENT
Department. Our aim is to assess the usefulness of VitalStim ® which is an external
neuromuscular electrical stimulation device to treat these patients. Material and
methods: Twenty patients who attended our Dysphagia clinic from November 2011 to
May 2012 complaining of dysphagia . Videoendoscopy assessment of swallowing and
surface electromyography were performed, using the Swallowing work station
(KayPentax ®). These patients were diagnosed of propulsive deficit with
videoendoscopy and had a high value of voltage in the electromyography. The severity
of dysphagia was assessed with the EAT-10 questionnaire (Eating Assessment Tool 10)
before and after the treatment. The rehabilitation with VitalStim® consists in ten
sessions of non-invasive electrical stimulation of the suprahyoid muscles. Results: The
mean score of pretreatment EAT-10 questionnaire was 15.5 (range 0-40) and the mean
score after treatment was 10.1 (Wilcoxon test, p value <0.002) . The mean value of the
voltage amplitude before the treatment was 97.8 µVolt and the mean value of the final
voltage was 87.55 µVolt (Wilcoxon test, p value 0.234). Discussion: Patients who were
treated with VitalStim ® therapy improved the score in the EAT-10 questionnaire . Noninvasive electrical stimulation of the suprahyoid muscles is useful for the treatment of
dysphagia in patients with propulsive deficit.
13.01
Bolus rheology and tongue pressure: the two important factors of bolus
swallowing
Chen, Jianshe; Alsanei, Woroud
University of Leeds, Leeds, United Kingdom
Introduction: There has been growing interests in the controlling mechanism of bolus
swallowing. We believe that, in order to have a safe swallow, the pressure required for
bolus flow along the oropharyngeal-oesophagus tract must be matched by the oral
(tongue) pressure one can create. In this work we tested this hypothesis by
investigating individuals’ tongue pressure and capability of swallowing. Materials and
Methods: 105 health subjects (aged 22 to 94) were recruited for this study. Their
tongue pressure was measured using the Iowa Oral Performance Instrument (IOPI).
Bolus samples were prepared from either commercial food products or thickeners. Bolus
rheological properties were characterised using a Bohlin CVO Rheometer. Selected
panellists were invited to swallow food samples and then to assess easiness attributes
of swallowing. Results: Tongue pressure measurements showed: (1) a huge variation
among human populations, from 20 to over 70 kPas; (2) no statistical difference for
subjects within the age groups below 60s; but a decreased tongue pressure for elderly
people (above 60); (3) on average a higher tongue pressure for males than for females.
Bolus swallowing tests showed that the oral transit time (OTT) and the sensed
difficulties of swallowing increased with increased bolus consistency. Further tests are
now on the possible correlation between the tongue pressure and bolus viscosity.
Discussion: Preliminary results suggest that individual’s swallow capability varies,
dependent on one’s capability in creating oral/tongue pressure. The matching between
the tongue pressure and the pressure required for bolus flow will be the key criterion for
bolus swallowing.
13.02
A numerical analysis of the extensional flow through the pharynx
Ascanio, Gabriel1; Salinas, Martin2; Brito-de la Fuente, Edmundo1; Gallegos, Crispulo1;
Vicente, William2; Marquez, Jorge3
1
Fresenius-Kabi Deutschland, Bad Homburg, Germany; 2Instituto de Ingenieria, UNAM,
Mexico, Mexico; 3CCADET, Universidad Nacional Autonoma de Mexico, Mexico, Mexico
Introduction: To numerically analyze the extensional flow through the pharynx from the
glossopalatal junction (GPJ) to the upper esophageal sphincter (UES). Numerical results
provide information about the strain rate field as a function of the peristaltic wave,
which can be used to estimate the extensional viscosity of the fluids flowing through the
pharynx. Method(s): Three dimensional meshes were built based on the axisymmetric
two-dimensional meshes reported in the literature. From the axial velocity fields, the
strain rate has been obtained along the pharynx at every time step. The Navier-Stokes
equations governing the flow have been numerically solved by means of the high-order
finite difference method considering a non-Newtonian fluid having a consistency index k
= 20.5 Pa•sn, a flow behavior index n = 0.39 and a density ρ of 1800 kg/m3. Result(s):
The axial velocity fields revealed a central stream with a speed higher than 1 m/s and
two symmetrical loops. From the strain rate distribution, it was observed that the bolus
is elongated as a result of the peristaltic wave. The ratio of the bolus head velocity to
the bolus tail velocity at the highest peristaltic wave investigated reached a value higher
than 3. Discussion: The extensional non-Newtonian flow through the pharynx from the
GPJ to the UES has been numerically analyzed. Three-dimensional flow fields reveal the
appearance of a central stream with two symmetrical loops. The strain rate fields
revealed that bolus head moves at least three times faster than bolus tails, so that the
bolus is elongated leading to think that the flow along the pharynx is mainly extensional
13.03
Therapeutic effect of xanthan gum-based thickener on swallowing function in
patients with oropharyngeal dysphagia
Rofes, Laia1; Arreola, Viridiana2; Mukherjee, Rajat3; Clavé, Pere1
1
CIBERehd - Hospital de Mataró, Mataró, Spain; 2Hospital de Mataró, Mataró,
Spain; 3Nestec Ltd, Lausanne, Switzerland
INTRODUCTION: Starch-based thickeners improve safety of deglutition but increase
residue. We aimed to evaluate the therapeutic effect of a xanthan gum-based thickener,
Resource®ThickenUp Clear (RTUC, Nestlé Health Science). MATERIAL AND METHODS:
We studied 120 patients with OD with videofluoroscopy while swallowing a series of 520 mL liquid boluses at nectar, thin and extreme spoon-thick (EST) viscosities
measured at 50/s 20°C and obtained with a hydrosoluble X-Ray contrast (50/50 vol
with water) and RTUC. We assessed prevalence of penetrations and aspirations for
impaired safety, oropharyngeal residue for impaired efficacy, bolus velocity, timing of
the swallow response, and the nutritional risk (MNASF, NRS 2002). RESULTS:
Prevalence of malnutrition or risk of malnutrition was 71% according to MNA-SF and 76%
according to NRS 2002. Increasing bolus viscosity: a) improved safety of swallow as 24%
of patients with OD presented safe swallow at thin, 55% at nectar (P<0.001) and 85%
at EST (P<0.001). Prevalence of aspiration was 16% at thin, 9% at nectar (P<0.01)
and 5% at EST (P<0.01). The score of the penetration-aspiration scale was 3.3±0.2
(thin), 2.2±0.2 (P<0.001, nectar) and 1.5±0.1 (P<0.001, EST); b) did not enhance
oropharyngeal residue; c) did not affect timing of swallow response; d) reduced bolus
velocity from 0.25±0.01m/s at thin to 0.21±0.01m/s at EST (P<0.05). DISCUSSION:
Prevalence of malnutrition among neurological and older patients with OD is very high.
Increasing bolus viscosity with RTUC exerts a strong therapeutic effect by improving the
safety of swallow without increasing oropharyngeal residue, an advantage of new
generation versus conventional thickening agents. This effect might help to improve the
nutritional treatments for these patients.
13.04
Carbonated liquids as a compensatory strategy for people with dysphagia
post-stroke
Tegou, Georgia1; Sdravou, Katerina2; Dagdilelis, Lukas3; Walshe, Margaret1
1
Department of Clinical Speech & Language Studies, Trinity College Dublin, Dublin,
Ireland; 2Arogi Euromedica Rehabilitation & Recovery Center, Thessaloniki,
Greece; 3Radiology Department, General Hospital "G. Papanikolaou", Thessaloniki,
Greece
Introduction: Research suggests that manipulation of bolus characteristics can induce
changes in swallowing physiology, improving swallow efficiency and often reducing the
risk of aspiration in people with dysphagia following stroke. Specifically, the evidence is
limited on chemesthetic properties such as carbonation to improve swallowing. This
study aims (1) To explore the effects of carbonated thin liquids (CTL) on the penetration,
aspiration and timing of swallow, delayed initiation of swallow and oropharyngeal
dysphagia post stroke. (2) To examine patients’ compliance with CTL once
recommended. Method: Fifteen participants with delayed initiation of swallow and
dysphagia post stroke were evaluated using videofluoroscopy on 5ml, 10ml and 25ml
swallows of non-carbonated thin liquids (NCTL) and CTL. Outcome measures were
penetration-aspiration (PA), bolus clearance (PR), initiation of pharyngeal swallow (IPS),
oral transit time (OTT), pharyngeal transit time (PTT), stage transition duration (STD)
and laryngeal closure duration (LCD). Views of participants on carbonated thin liquid
intake were obtained on questionnaire. Results: A statistically significant improvement
for PA scores on CTL was found for 5ml and 10ml boluses (p<0.05). Participants
exhibited faster initiation of pharyngeal swallow for 5ml CTL with an overall trend of
improvement in temporal measures. Questionnaire, despite low response rate (3/9),
revealed a positive attitude toward carbonated fluid intake. Disussion: Research and
clinical implications are discussed as incorporation of CTL in the diet of such population
can be a challenge depending on conditions of everyday life.
Posters presented as Mini-Orals
08.01
The effect of 5hz high-frequency repetitive transcranial magnetic stimulation
on contra-lesional swallowing motor cortex in post-stroke dysphagic patients;
a randomized controlled study
Park, Jin-Woo
Dongguk University Ilsan Hospital, Goyang-si, Korea, Republic of
Introduction: Dysphagia is a common problem after stroke and one of the most
important causes for post-stroke death. Various treatments for dysphagia were
suggested but the evidence for the effects is insufficient. Recently researches about
repetitive transcranial magnetic stimulation (rTMS) which was applied for helping
neurologic recovery after stroke are on-going. In this study, we intend to find the
therapeutic effect of 5Hz high-frequency rTMS on contra-lesional swallowing motor
cortex in post-stroke dysphagic patients. Materials and Methods: Eighteen patients with
unilateral hemispheric stroke dysphagia lasting more than 1 month were randomly
divided into two groups. They all performed videofluoroscopic swallowing study (VFSS)
before rTMS intervention. Experimental group (EG) received 5Hz rTMS on contralesional swallowing motor cortex for 10 minutes per day for 2 weeks. Control group (CG)
received sham stimulation under same condition. VFSS were performed again just after
treatment cessation and two weeks later. The evaluation was performed using
videofluoroscopic dysphagia scale (VDS) and penetration-aspiration scale (PAS). Results:
After rTMS, there was a significant improvement of swallowing function in EG (both VDS
and PAS; p<0.05). This effect lasted up to two weeks after treatment. However, there
was no change in CG. Discussion: 5Hz high-frequency rTMS on contra-lesional
swallowing motor cortex might be beneficial for post-stroke dysphagic patients. This
intervention can be used as a new treatment method in post-stroke patients with
dysphagia.
08.02
Effects of repetitive transcranial magnetic stimulation and neuromuscular
electrical stimulation on dysphagia on dysphagia in patients of unilateral
hemispheric stroke
Li, Bingjie
China Rehabilitation Research Center, Beijing, China
Introduction:Repetitive transcranial magnetic stimulation(rTMS) and Neuromuscular
electrical stimulation (NMES) are new therapeutic strategies for dysphagia. However,
the scientific evidence of their efficacy is still unclear and commands further researches .
The research was designed to explores effects of these treatment modalities in the basis
of videofloroscopic swallowing study . Methods:67 patients with dysphagia due to
monohemispheric stroke were randomly divided into group A,B and C.Patients in group
A received repetitive rTMS and sham NMES. Patients in group B received sham rTMS
and NMES. Patients in group C received sham rTMS and sham NMES. All the patients
received traditional swallowing therapy at same time. The evaluation was performed
with videofluoroscopy swallowing study.Rosenbek Penetration-Aspiration scale and
multiple kinematic parameters of swallowing were used to identify the differences
among three groups before and immediately after treatments. Results: There were no
significant inter-group differences in the baseline data of age, gender£¬the scores of
PAS and kinematic parameters . After treatments, the scores of PAS and most
kinematic parameters of swallowing showed the significant difference in group A. In
group B and C, the scores of PAS decreased ,PDT was improved. A significant
improvement of swallowing function was found in group A when compared with the
other two groups. There were no significant differences between group B and C in the
scores of PAS and most kinematic parameters of swallowing function, expect
PDT .Conclusions: rTMS might be a useful tool for phagia ,but the future researches are
needed to determin optimal strategy of rTMS. NMES failed to improve swllowing
function for the chonic dysphagia in post-stroke patients.
08.03
Sustained frequency dependent changes in human pharyngeal motor cortex
excitability can be induced by neuronavigated cerebellar repetetive
transcranial magnetic stimulation (rtms)
Vasant, Dipesh; Mistry, Satish; Jayasekeran, Vanoo; Michou, Emilia; Hamdy, Shaheen
University of Manchester, Salford, United Kingdom
Introduction: Recently we have demonstrated that single-pulse transcranial magnetic
stimulation (TMS) of the human cerebellum can directly evoke muscle responses in the
pharynx and induce short-term excitation of pharyngeal motor cortex (Jayasekeran et al,
2011). The aim of this study is to determine if longer trains of rTMS can induce longlasting changes in pharyngeal cortical excitability. Materials and Methods: In this
preliminary report of 5 healthy adults (2 male, 23-61 years old), anatomical brain scans
were acquired. During subsequent experimental sessions, at least a week apart,
participants were randomised to receive one of 5 frequencies of neuronavigated
cerebellar rTMS (Sham, 1Hz, 5Hz, 10Hz and 20Hz). During each session, pharyngeal
cortical excitability (in both hemispheres) was measured using TMS and pharyngeal
electromyography (recorded via an intraluminal catheter) at baseline and for up to one
hour post cerebellar rTMS. Abductor pollicis brevis (APB) recordings were used as
control. Data were compared using repeated measures ANOVA. Results: Compared to
Sham, 10Hz cerebellar rTMS increased pharyngeal cortical excitability in the hemisphere
contralateral to cerebellar stimulation (max 181%, p<0.035) (Figure 1). In contrast,
1Hz, 5Hz and 20Hz rTMS cerebellar conditioning did not significantly alter pharyngeal
excitability compared to Sham. APB responses were not significantly different to sham
after any intervention. Discussion: Our preliminary data show for the first time that
sustained changes in swallowing motor pathways can be induced using 10Hz cerebellar
rTMS, and may also extend to the other frequencies tested with greater participant
numbers. Cerebellar rTMS may therefore have novel therapeutic potential in the
treatment of dysphagia after stroke.
08.04
Effect of tongue strength training in head and neck cancer (hnc) patients
treated with chemoradiation (crt) or radiotherapy (rt)
Van Nuffelen, Gwen1; Vanderwegen, Jan2; Guns, Cindy1; Van den Steen, Leen1; De
Bodt, Marc1
1
Antwerp University Hospital, Edegem, Belgium; 2CHU Saint-Pierre, Brussels, Belgium
Introduction Previous research indicates that isometric tongue pressure training
improves tongue strength and swallowing in dysphagic stroke patients (Robbins et al.,
2007; Yeates et al., 2008). Data on HNC patients are however lacking. The purpose of
this study was to investigate the effect of an exercise scheme on tongue strength (TS)
in HNC patients previously treated with CRT or RT, with pharyngeal residue and reduced
TS. Methods 6 dysphagic HNC patients suffering from longterm (2-14 years post
treatment) effects of CRT or RT, with decreased anterior and posterior TS (on average
17 kPa below normative value) and resulting vallecular residue were treated using the
IOPI device. During 4 weeks (5x/week) they completed an experimental therapy
protocol, including both isometric strength and endurance tasks. Outcome data were
anterior and posterior TS at baseline and after completing 20 training sessions.
Wilcoxon testing and Pearson Correlation Coefficient (r) were used for the statistical
analyses. Results Anterior TS improved from 22,76 to 31,12 kPa (p=0.08) and posterior
TS increased from 21,24 to 29,61 kPa (p<0.05). The correlation between baseline TS
and degree of improvement was weak (anterior: r=0.028; p=0.96 - posterior: r=0.482;
p=0.333). Discussion This study indicates that the proposed tongue strengthening
protocol can improve tongue strength in dysphagic HNC patients with decreased tongue
strength following RT or CRT. Further research is obviously needed. The used training
protocol will be presented during the presentation.
08.05
The effect of palatal augmentation prosthesis in head and neck cancer patients
with dysphagia: a retrospective multi-center study
Nakajima, Junko1; Nohara, Kanji2; Takahashi, Koji3; Furuya,, Junichi4; Taniguchi,
Hisashi5; Nakane, Ayako6; Yoshikawa, Mineka7; Minagi, Shogo8; Ozawa, Shogo9; Ono,
Takahiro10
1
Department of Maxillofacial Surgery, National Defense Medical College, Tokorozawa,
Japan; 2Division for Oral-Facial Disorders, Osaka University, Dental Hospital, Osaka,
Japan;3Division of Oral Rehabilitation Medicine, Showa University, Tokyo, Japan; 4Dept
of Prosthodontics & Oral Implantology, School of Dentistry, Iwate Medical University,
Morioka, Japan; 5Dept of Maxillofacial Prosthetics, Graduate School, Tokyo Medical and
Dental University, Tokyo, Japan; 6Dept of Gerodontology, GraduateSchool, Tokyo
Medical and DentalUniversity, Tokyo, Japan; 7Dept of Advanced Prosthodontics,
Graduate School, Hiroshima University, Hiroshima, Japan; 8Dept of Occlusal & Oral
Functional Rehabilitation, Graduate School, Okayama University, Okayama,
Japan; 9Dept of Removable Prosthodontics, School of Dentistry, Aichi Gakuin University,
Nagoya, Japan; 10Dept t of Prosthodontics, Gerodontology & Oral Rehabilitation,Osaka
University Graduate School of Dentistry, Osaka, Japan
Introduction: In postoperative patients for head neck cancer (HNC), restricted tongue
mobility may cause swallowing disorders. The Palatal augmentation prosthesis (PAP)
has been utilized for such patients to facilitate tongue-palate contact during swallowing.
Up to now, no standardized evaluations have been conducted for large numbers of
patients. This multi-center study investigated the effects of PAP on post HNC surgery
patients with dysphagia in Japan. Material and Methods: Retrospective evaluation of
treatment outcome with PAP was conducted on 71 patientsf file (52 men and 19
women; mean age 64.4 ± 12.3years) from fifteen dental and medical facilities. Diet
tolerance, Functional Oral Intake Scale (FOIS), patientsf self-assessment and VF
findings were used for treatment outcome measures. Multiple regression analysis was
performed for each outcome measures with the explanatory variables of the extent of
surgical resection and postsurgical tongue mobility. Results: We found significant
improvements for diet tolerance (41/71), FOIS (45/71), subjective evaluation for
swallowing (57/71) and speech (54/71). Only four patients showed no changes with
PAP. The VF findings for 25 patients revealed significant improvements in oral residue,
penetration-aspiration scale, pharyngeal residue and hyoid movements. The Multiple
regression analysis detected no correlation between outcome measures and explanatory
variables mentioned above. Discussion: Although PAP was effective for improving
dysphagia in most patients, the predictive factors for the prognosis with PAP could not
be identified based on the surgical factors, thus suggesting the possibility that the state
of tongue-palate contact with PAP may affect the treatment outcome.
08.06
Clinical and endoscopic characteristics of neurogenic dysphagia syndromes
Avdyunina, Irina1; Selivanov, Vladimir1; Inkina, Anna2; Chernikova, Lyudmila1
1
Research Center of Neurology, RAMS, Moscow, Russian Federation; 2Moscow Regional
Research Clinical Institute n.a. M.F. Vladimirsky, Moscow, Russian Federation
Introduction. Manifoldness and variety of symptom combinations in neurogenic
dysphagia (ND) “dissolve nosologic boundaries” and determine the necessity of its
functional correction. The aim of the study was to estimate correlation between ND
syndromes and their clinical and endoscopic characteristics. Materials and Methods. 102
patients (mean age 54.6±14.4 years) with neurogenic dysphagia (ND) of different
severity were investigated. Diagnoses included stroke, peripheral neurogenic
dysfunction and other neurological diseases. Clinical bedside examination together with
fiber optic swallowing examination let analyse level and severity defect, swallowing
safety and efficacy and confirm diagnosis. Results. Symptom compositions of abnormal
swallowing were unique for each patient. We distinguished following ND syndromes:
“disturbance of food bolus forming” (32.4%); “disturbance of airway protection”
(80.7%); “bulbar” (44.1%); “pseudo bulbar” (52.9%); “cricopharyngeal achalasia”
(15.7%); “disturbance of upper airway patency” (5.9%). Most patients had several
syndromes. Specific for the first syndrome was bolus leaking (rs=0.78, P<0.05), its
accumulation in pharynx (rs=0.77, P<0.05), regurgitation (rs=0.67, P<0.05); for the
“bulbar” – wet voice (rs=0.75, P<0.05); for the “pseudo bulbar” – bolus leaking
(rs=0.71, P<0.05), its accumulation in pharynx (rs=0.6, P<0.05); for the
“cricopharyngeal achalasia” – epiglottis dysfunction (rs=0.57, P<0.05), aspiration
(rs=0.55, P<0.05). Wet voice (rs=0.83, P<0.05), rhinolalia (rs=0.58, P<0.05),
aspiration (rs=0.53, P<0.05) associated with severe ND. Discussion. Syndrome
differentiation in ND using endoscopic evaluation of swallowing is essential for
successful functional rehabilitation.
08.07
Effect of tracheostomy tube occlusion in patients with neurogenic dysphagia
Ledl, Christian; Knerr, Ylva; Bader, Peter
Schoen Klinik Bad Aibling, Bad Aibling, Germany
Introduction: As a consequence of tracheostomy, airflow is guided via the tracheostomy
tube and the upper airway is uncoupled. By occluding tracheostomy tubes, this effect
can be reversed and the airflow can be led via the mouth. The purpose of this study is
to describe the effect of tracheostomy tube occlusion (breathing via mouth versus
breathing via tracheostomy tube) on pharyngeal phase physiology and on therapeutical
standards in patients with neurogenic dysphagia. Methods: In a prospective randomized
study manometric measurements were performed in the oropharynx, hypopharynx and
in the UES during 5ml bolus swallows (5 repetitions per patient and per condition).
Fifteen cannulated patients were investigated each under two conditions: 1) with open
tracheostomy tube and 2) with closed tube. Placement of the manometric catheter was
controlled endoscopically. Analysis parameters were onset, duration and maximum
generation of pressure. Results: Maximum oropharyngeal pressure was 68.5 mmHg in
the open condition, 63.8 mmHg in the closed condition (mean values). Hypopharyngeal
pressure reached 85.9 mmHg (open) versus 75.6 mmHg (closed). Pressure waves in
the oropharynx lasted for 0.7 sec versus 0.68 sec, in the hypopharynx for 0.7 sec
versus 0.67 sec. Maximum UES relaxation was -8.3 mmHg versus -7.4 mmHg. None of
these parameters showed significant differences between the open tube versus closed
tube condition (t-test,2-sided significance). Discussion: Occlusion of tracheostomy
tubes does not alter pharyngeal and UES pressure measurements in patients suffering
from neurogenic dysphagia. No therapeutic advantages concerning strength or timing of
the pharyngeal wave can be attained. These results are in accordance with findings in
healthy subjects or non-neurogenic patient groups.
08.08
Coordination of breathing and swallowing in rats with pulmonary emphysema
Ghannouchi, Ines; Marie, Jean Paul; VERIN, Eric
Rouen University, Rouen, France
Introduction : Temporal coordination of swallowing and ventilation is essential to
prevent pulmonary aspirations. In healthy individuals, breathing is interrupted during
swallowing and resumes in the expiratory phase. Changes in the pattern of breathing or
ventilation can influence the coordination of swallowing and ventilation. Patients with
COPD can be susceptible to changes in the coordination of swallowing due to impaired
lung function. In fact, it has been reported that patients with COPD tend to interrupt
breathing during swallowing and resume it in the inspiratory phase which increase
exacerbation. The aim of this study was to study the swallowing function as well as the
coordination swallowing - ventilation in unrestrained rat with emphysema. Methods :
The study was carried out on 27 male Sprague-Dawley rats (2–3 months, 275–300 g)
subdivided in 3 groups (G1 : Healthy control rats, G2 : rats with a severe model of
emphysema and G3 : rats with a mild model of emphysema) using whole-body
plethysmography and video recordings. The rats were given water via a baby bottle
fitted with a nipple after 24 h without drinking. The experiment was continued until rest
ventilation and swallowing periods were identified on the video recordings. Results : No
change in the ventilatory parameters occured when compared the emphysema groups
with the healthy control. During swallowing, in the G2, there was an increase in
swallowing frequency (SF= 20±3) when compared to G1 (p<0.01) and G3 (p<0.05)
with no change in % I-I (p>0.05). Conclusion : From this study on animals we could
conclude that there is no change in the coordination swallowing – ventilation in stable
emphysema.
08.09
Surgical management of intractable aspiration
Nito, Takaharu; Imai, Naoko; Yamauchi, Akihito; Ueha, Rumi; Yamasoba, Tatsuya
University of Tokyo hospital, Bunkyo-ku, Japan
Introduction: Surgery for intractable aspiration, which can be life-threatening, has been
widely implemented. The purpose of this study is to elucidate the effectiveness of
surgery for intractable aspiration. Materials and Methods: The subjects were 42 patients
who underwent surgery for intractable aspiration from 2006 to 2011. Retrospective
charts of the patients and thhe responses of the patients and their families to a
questionnaire were reviewed. Results: Fifteen patients had amyotrophic lateral sclerosis,
eight multiple system atrophy, five brain vascular disorder, two Parkinson disease, and
twelve other diseases. Thirty patients underwent laryngeal closure. Ten patients
underwent laryngotracheal separation or diversion. Two patients underwent total
laryngectomy. Twenty-seven patients and their families responded the questionnaire.
Eight patients became able to take general or soft diet orally. Eighteen patients were
able to eat pureed foods or drink liquids for pleasure. One patient was unable to take
anything orally. Patients with slowly progressive or stabilized diseases were able to take
food orally for over one year. However, patients with rapidly progressive diseases
showed a decreased ability to take food orally. Twenty-four families and 21 patients
answered gsatisfiedh or hslightly satisfiedh to the question gAre you satisfied
with the result of the surgery?h Discussion: It is possible for almost all the patients
who underwent surgery for intractable aspiration to take food or liquid orally at varying
degrees. Oral intake can be one of the few pleasures for the patients with decreased
motor function. Surgery for intractable aspiration is effective and should be considered.
08.10
Functions of the upper aero digestive tract following radiotherapy and / or
chemotherapy for laryngeal carcinoma
Bogaardt, Hans1; Heijnen, Bastiaan J.2; Baijens, Laura3; Koetsenruijter, Krista3
1
Department of Speech and Language Pathology, HAN University of Applied Sciences,
Nijmegen, Netherlands; 2Leiden University Medical Center, Leiden, Netherlands; 3Dept.
of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical
Centre, Maastricht, Netherlands
Introduction: Patients with head and neck cancer suffer from various functional,
physical, and emotional impairments due to the primary illness as well as due to the
secondary consequences of the oncological treatment. The present systematic review
describes the functions of the upper aerodigestive tract following radiotherapy and/or
chemotherapy in patients with head and neck cancer. Materials and Methods: A
systematic literature search was performed by two independent reviewers using the
electronic databases PubMed and Embase. All inclusion dates up to may 2010 were
included. Mesh-terms were supplemented by free text words. Results and Discussion:
Out of 1313 abstracts, twenty articles met the inclusion criteriaIn general, voice quality
improved after intervention, whereas QoL, the severity of dysphagia and the amount of
oral intake deteriorated during as well as after treatment for a longer period of time.
However, as a consequence of the diversity in treatment protocols and patient
characteristics, conclusions of most studies cannot be generalized easily to one another.
Further research on the effects of oncological interventions on the upper aerodigestive
tract are needed.
10.01
First congress of the european society for swallowing disorders 2011
Speyer, Renée1; Martin, Wendy2
1
HAN University of Applied Sciences, Nijmegen, Netherlands; 2Fresenius Kabi
Deutschland GmbH, Bad Homburg, Germany
Introduction In 2011 the first Congress of the ESSD was held in Leiden, the Netherlands.
Participants from 27 countries attended the ESSD meeting. The purpose of this pilot
study was to gain insight in the participants’ professional background, work settings, as
well as their general knowledge and training in dysphagia. Materials and Methods
During two consecutive workshops, a questionnaire was presented. Anonymous data
were gathered from 132 participants out of 235 ESSD registrants. Results The majority
of the participants were SLP’s (61 %), physicians (18%) and nutritionists (8%). Most
attendees were active in acute health care (41%) or rehabilitation centers (23%). Over
85 % participated in multidisciplinary teams. Participants showed a great variety in
expertise with dysphagia: ranging from less than two years (23 %) to more than 15
years of experience (29%). The acual time spent on working with dysphagia showed
great diversity as well. Only 8 % of the participants worked full-time with dysphagic
patients. About 50% had direct access to VFS at work, some 25% had off-site access,
whereas 16 % of the participants lacked VFS access. Almost 60 % carried out less than
one assessment per week. Fifty percent of all attendees had received no prior training
on VFS analysis. When discussing casuistry, most participants lacked sufficient
consensus on diagnosis or treatment aspects. Discussion and Conclusion The ESSD is
an international society whose members differ greatly in professional background,
expertise and training. Data suggest the need for specialized training in oropharyngeal
dysphagia for health care providers.
10.02
Assessment of mastication in healthy and cp-children; a validity and reliability
study
Remijn, Lianne1; Speyer, Renee2; da Costa, Saakje3; van Limbeek, Jacques4; Nijhuisvan der Sanden, Maria5
1
Sint Maartenskliniek, Nijmegen, Netherlands; 2University of Applied Sciences, Institute
of Health Studies, Nijmegen, Netherlands; 3HanzeHogeschool, Groningen,
Netherlands; 4de Viersprong, Nijmegen, Netherlands; 5Radboud University Nijmegen
Medical Centre, Scientific Institute for Quality of Care, Nijmegen, Netherlands
Introduction: To develop the Mastication Observation and Evaluation (MOE) instrument
to observe and assess the chewing ability of children eating solid or lumpy food. This
study describes the process of item definition, selection and scoring system (content
validity) and the reproducibility of the MOE when used by different observers. Methods
and Materials: The validation study was in-line with the COSMIN checklist. In the first
phase a panel of 15 experienced speech therapists assessed the relevance of 17 original
items and the item description by using the Delphi technique over three rounds. The
level of agreement was calculated with Content Validity Index (CVI). Items with an
agreement of > .75 were included in the list. To test the reproducibility, two experts
and five students assessed 20 randomly selected video tapes of 10 children with
cerebral parese (aged 2 to 6 years) and 10 healthy children (aged 6 to 48 months)
eating bread and a biscuit. The reliability was estimated by intraclass correlation
coefficient (ICC). Results: 15 oral motor behaviours of the MOE were supposed to be of
a distinctive value as a result of >.75 agreement reached in three Delphi rounds. All
items showed a good to excellent level of intra-observer agreement (ICC; 0.73-1.0) and
inter-observer agreement (ICC experts; 0.68-1), except one item concerning chewing
duration. As result of limited discriminative value four items were reduced to two items.
Conclusion; A total of 12 oral motor behaviours were included into the MOE for
assessing the mastication in children.
10.03
Improving patient accesss to videofluoroscopy services: role of the
practitioner-led clinic
Newman, Roger D.1; Knightingale, Julie M.2
1
Lancashire Teaching Hospitals NHS Trust,, Fulwood, United Kingdom; 2University of
Salford, Greater Manchester, United Kingdom
Quality Issue Although costly and time consuming, videofluoroscopic swallowing (VFS)
examinations are the gold standard for imaging of oro-pharyngeal dysphagia, and
demand is likely to increase with an ageing population. Traditional radiologist-led VFS
services in the UK are gradually being replaced by practitioner-led clinics undertaken
jointly by speech and language therapists and radiographers. This article explores the
impact on patient access of a practitioner-led VFS clinic at a large teaching hospital.
Initial Assessment Specific information pertaining to VFS patient waiting times and
service quality was collected for a twelve month period both pre- and post-clinic
formation. Choice of Solution Additional capacity was achieved with the introduction of
the practitioner-led clinic, with overall patient access improving by 111%. Mean waiting
times for in-patients reduced by 75%, many of whom had the procedure on the same
day as referral, with out-patients waiting times reducing by 62.5%. Evaluation The data
demonstrates that patient access and report turnaround times are significantly
improved, with no adverse effects as measured by inadequate studies, incorrect reports,
complaints and documented radiation dose levels. Lessons Learnt Practitioner-led VFS
services can be recommended as a safe and efficient method of improving service
provision.
10.04
Comparing the rheology of different brands of thickened infant formula and a
pre-thickened infant formula
Cichero, Julie1; September, Cindy2; Nicholson, Timothy2
1
School of Pharmacy, The University of Queensland, Brisbane, Australia; 2School of
Chemical Engineering, The University of Queensland, Brisbane, Australia
INTRODUCTION: 25-55% of premature infants and 60% of babies with a developmental
disorder have difficulty swallowing (dysphagia). In the first 3-6 months, infants depend
solely on milk feeds for nutrition. Provision of thickened milk is one treatment used to
manage dysphagia. Although various preparations are used, there is little information
about: how similar these products are objectively, thickening over time, behaviour of
thickener concentration or differences in outcome when large and small volumes are
mixed. In this study the rheological parameters of different brands of infant formula
thickened with powder, and a pre-thickened formula are compared. METHODS: An
industry standard food thickener was added to three different types of infant formula.
The thickened infant formulas and one pre-thickened formula were then characterised
in a strain-controlled rheometer at a fixed temperature of 38°C. Tests conducted
include small strain oscillatory tests (time sweeps, frequency sweeps) step rate tests
and steady shear tests. RESULTS: All of the thickened infant formulas took about 10
min to thicken to a uniform level, whereas the pre-thickened formula almost
immediately thickened. The step rate tests indicated that there is a small apparent yield
stress in all of the formulas. DISCUSSION: This initial work has established the required
thickening time for thickened infant formula. Clinically important outcomes were
determined. For example: small test volumes increase the variability; and the rules for
determining concentration of thickener are critical to provision of a thickened milk that
maximises the nutritional needs of babies with dysphagia, whilst reducing the potential
for aspiration.
10.05
Analysis of duration of the oral and the pharyngeal phases of swallowing of
hard gelatin capsules in asymptomatic adults and elders
Paiva, Deborah Brandão; Takase, Érica Mayumi; Crespo, Agrício Nubiato; Barcelos,
Irene Harumi Kamata; Mourão, Lucia Figueiredo
Faculty of Medical Sciences - University of Campinas, Campinas, Brazil
Introduction
Difficulty to swallow capsules is a common complaint among the elders. However, the
literature comprises few studies concerning time measurement of capsules swallowing.
This study analyzes the duration of the oral and the pharyngeal phases of swallowing in
asymptomatic adults and elders in swallowing hard gelatin capsules with liquid and with
pudding consistencies.
Method
60 adults (27-55 years of age) and 50 elders (65-92 years), 77.8% of which being
females, with no swallowing complaints or any associated clinical conditions, were
studied by videofluoroscopy (VFSE). For the evaluation, hard gelatin capsules size 00
filled with barium were offered with liquid and with pudding consistencies. The images
were analyzed frame by frame using Virtual Dub Software. The investigator randomly
selected and reanalyzed 30% of the subjects VFSE tapes to evaluate intrajudge
reliability. For interjudge reliability, the results of the first investigator were compared
with the results of a second certified speech pathologist. Fisher's Exact Test,
significance 0.05, was used for the statistical analysis.
Results
Compared to adults, elders presented:
• Longer oral phase with liquid consistency (p=0.0032);
• Longer pharyngeal phase with liquid consistency (p<0.001);
• Similar oral phase with pudding consistency (p=0.2344);
• Longer pharyngeal phase with pudding consistency (p<0.001).
Discussion
The duration of the oral and the pharyngeal phases with liquid and with pudding
consistencies is longer with elders, except for the oral phase with pudding consistency.
The use of pudding consistency increases the stimuli of sensorial receptors on elders,
favoring an improved oral motor control when swallowing capsules.
10.06
Swallowing disorders in a institutionalized geriatric population: does the
opinion of the elderly, the slp and the staff CONVERGE?
Nogueira, Dália1; Reis, Elizabeth2; Lopes, Inês3; Colaço, Teresa4
1
Lisbon University Institute& Escola Superior de Saúde de Alcoitão, Cascais,
Portugal; 2Lisbon University Institute, Lisboa, Portugal; 3University of Coimbra, Coimbra,
Portugal;4Speech Care, Lisboa, Portugal
Introduction: Cognitive disorders, common in institutionalized elderly, can lead to an
erroneous self perception of their swallowing functions. Also non specialized staff can
act in a non proper way. Noncompliance with SLP’s recommendations and the
inadequate estimation of patients ‘functional abilities by the staff have been a serious
problem that may subvert the best practices. Material and Methods: The purpose of this
study is to evaluate the swallowing patterns among a community of nursing home
residents and compare the SLP assessment with the individuals’ difficulties and the staff
opinion. Subjects were 150 elderly living in nursing homes. For those unable to
collaborate, a record of their eating process and staff opinion was collected.
Sociodemographics variables as well as elderly's functional status were registered. To
evaluate the swallowing function, the 3oz water test and the Quick Assessment
Questionnaire for Dysphagia were applied. Residents were asked for fill the EAT 10 and
a questionnaire was applied to the staff. Finally, the results of the SLP assessment, the
self perception of the elderly and staff opinion were compared using statistic descriptive
analysis, correlation and association measures. Results: SLP’s assessment identified a
high proportion of individuals with signs of dysphagia, many of them not identified by
the staff. The elderly's self perception differed also, in many cases, from the SLP
evaluation Discussion: Identification of clinical signs of dysphagia contributes to prevent
its severe consequences. However, if the individual and the nursing home staff don´t
act in accordance with the severity of the problem and SLP recommendations, this
situation exposes the elderly to constant risks in everyday life.
10.07
Adaptation and assessment of reliability and validity of the greek version of
the okhuma questionnaire for dysphagia screening
Papadopoulou, Soultana1; Ploumis, Avraam1; Exarhakos, Georgios2; Beris, Alexandros3
1
Physical Medicine and Rehabilitation Clinic, Ioannina, Greece; 2. Department of
Otorhinolaryngology, University of Ioannina Medical School, Greece, IOANNINA,
Greece; 3. Departments of Orthopaedic Surgery and Physical Medicine and
Rehabilitation, University of Ioannina Medical School, Greece, IOANNINA, Greece
Abstract Background: The Okhuma questionnaire is a validated screening tool originally
used to detect dysphagia among patients hospitalized in Japanese nursing facilities. It
has also been adapted and validated in the Italian language. The purpose of this study
is to evaluate the reliability and validity of the adapted Greek version of the Okhuma
Questionnaire. Methods: Following the steps of the cross-cultural adaptation into the
Greek language, the Okhuma questionnaire was completed by 123 patients hospitalized
at the University hospital and the Rehabilitation center of Ioannina Greece. These
patients were a mixed population of dysphagia sufferers (or suspicious of dysphagia)
following cervical spine disorders, brain lesions, cancer, other allied diseases and, also,
a random sample of patients irrespective of dysphagia. All of them completed the
questionnaire a second time within a month. Results: The Cronbach’s α coefficient of
internal consistency for the Dysphagia questionnaire was calculated as 0.894. Testretest reliability was assessed with the use of Cohen’s Kappa for each of the 15 items of
the questionnaire. Calculated values of the index ranged from 0.64 to 0.9. Pearson’s
correlation coefficient was also estimated for the test retest total score as 0.894
(p<0.0001). Content validity as assessed through factor analysis identified a single
factor, to which 13 of 15 questions contributed significantly, that accounted for 43% of
the total variance (p<0.0001). Conclusion: The adapted Greek version of the Ohkuma
questionnaire is a valid and reliable instrument for the diagnosis and treatment
outcome assessment of Greek speaking patients with dysphagia. Key words: Dysphagia
- Questionnaire - Validation - Deglutition - Deglutition disorders.
10.08
Cricopharyngeal botulinum toxin injection and rehabilitation in patients with
severe oropharyngeal dysphagia from inclusion body myositis
di Pede, Chiara1; Bonsangue, Valentina2; Marchese Ragona, Rosario3; Mion, Marta4;
Masiero, Stefano2
1
Medicina Fisica e Riabilitativa Università Padova, Padova, Italy; 2Medicina Fisica e
Riabilitativa, Padova, Italy; 3Otorinolaringoiatria, Padova, Italy; 4Otorinolarigoiatria,
Padova, Italy
Introduction
Inclusion body myositis (IBM) is an inflammatory myopathy with an incidence of 40-50%
of oropharyngeal dysphagia (OD). The aim of study was evaluating the efficacy of
botulinum toxin and rehabilitation treatment in patients with severe OD from IBM.
Materials and methods
We included 4 patients (3 females; 1 male, mean age 76 years) affected by IBM
reporting a history of progressive dysphagia who had an unsuccessful trial of swallowing
traditional therapy. Cricopharyngeal (CP) muscle dysfunction was noted in all patients
with barium swallow studies and fiberoptic endoscopic evaluation of swallowing.
Botulinum injection of the upper esophageal sphincter was performed in each side of CP
muscle every 4-6 months. All patients received logopedic therapy (dietary modifications,
postural technique, air flow protection manoeuvres). Outcomes were assessed using the
penetration-aspiration scale (PAS), patients' short-term (3 months) and long-term (36
months) subjective impressions of their ability to swallow.
Results
All patients obtained significant improvement in swallowing after the first injection.
Symptomatic improvement was noted in 3 cases with botulinum injection and had longterm benefits, evidenced by decreased aspiration symptoms (mean PAS at the start 6,
after treatment 2); one patient didn’t obtain clinical improvement from toxin injection;
he benefited from CP myotomy.
Discussion
No specific treatment for OD related to IBM has been described to date. Our preliminary
findings suggest a potential benefit from botulinum toxin treatment associated to
logopedic therapy in patients with IBM and underlying CP muscle dysfunction, resulting
in a long-term increase in swallow safety, without aspiration and decreased penetration.
10.09
Development of a protocol of evaluation of oropharyngeal dysphagia by the
col·legi de logopedes catalunya( clc)
Garcia, M.; Pastor, Bibiana; Ejarque, Judith
Col·legi de Logopedes de Catalunya Dysphagia Protocol, Barcelona, Spain
Introduction The incidence of oropharyngeal dysphagia is very high in patients with
neurological diseases of any age, in institutionalized elderly and as a consequence of
other disorders and surgical treatments. Speech pathologists specializing in dysphagia
are involved in the detection, evaluation, interpretation of clinical trials and treatment.
A consensus is needed on the warning signs and symptoms that are important in
determining whether swallowing is effective and safe. Materials and Methodology In the
absence of specific assessment tools for each pathology in speech therapy, in the year
2008 the CLC encouraged the development of evaluation protocols. This initiative, the
first of its kind in Spain, was built on proposals made in 2006 by the CLC Judicial
Commission of Experts, a collegial group responsible for drafting the speech therapy
evaluation protocol of Oropharyngeal Dysphagia. In 2011, the proposal was presented
to the collegiate for suggestions and consensus and also presented at the 3rd congress
of the CLC and is currently under review for publication and diffusion. Results This
protocol is the result of a literature review and of the experience of the participating
team. It consists of introduction and assessment protocols for swallowing in children
and adults. It is an effective tool to obtain the data necessary for the detection,
assessment and rehabilitation of this pathology. Conclusion The implementation of the
protocol in clinical practice will allow the validation of the document and start the next
stage: the process of developing a clinical practice guideline.
10.10
Volume viscosity test and pulseoximetry as screening for swallowing disorders
in subacute stroke patients.
Guillén-Solà, Anna1; Tejero, Marta2; Belmonte, Roser3; Escalada, Ferran4; Muniesa,
Josep Mª5; Marco, Ester5
1
Hospitals Mar-Esperança. Parc de Salut Mar, Barcelona, Spain; 2Hospital del MarEsperança, Barcelona, Spain; 3Hospital del Mar-Esperança.Parc de Salut Mar, Barcelona,
Spain; 4Barcelona, Barcelona, Spain; 5hospital del Mar-Esperança. Parc de Salut Mar,
Barcelona, Spain
Introduction: The purpose of this study was to assess the usefulness of Pulse Oximetry,
the Volume Viscosity Swallow Test (V-VST), and Videofluoroscopy for detecting
aspiration after stroke. Methods: Swallowing was assessed in 127 stroke patients (mean
age 66.8±12.4 years) within 15 days of symptom onset with a V-VST. Finally, 66
(52.1%) subacute stroke patients were undertaken with both assessments (V-VST and
Videofluoroscopy). Calculations were made of the following variables determining the
reliability and overall value of a diagnostic test sensitivity, specificity, negative
predictive value (NPV), positive predictive value (PPV), diagnostic accuracy and positive
and negative likelihood ratios (PLR/ NLR). Results: V-VST showed a safe swallow in 6
(9.09%), unsafe swallow in 60 (90.9%), and silent aspiration in 12 (18.18%) patients.
Crosstabs results for V-VST and videofluoroscopy, to detect aspiration, sensitivity and
specificity were 100% and 13.6%, respectively. PPV and NPV were 36.7-100%. With an
accuracy for V-VST of 42.4%. Likelihood ratios for V-VST were: NLR 0, PLR 1.06.
Conclusions: The V-VST showed a good sensitivity but lower specificity, for detection of
aspiration compared with videofluoroscopy in stroke patients. It is a low-cost, easy to
use and very sensitive screening test to detect potential aspiration. It fulfils the
requirements of a screening test, but not those of a diagnostic test.
Posters
PA.01
Oropharyngeal dysphagia in acute stroke patients: results of nursing
assessment
Sebastián, Marisa1; Palomeras, Ernest2; Monteis, Rosa1; Fàbregas, Cristina1; Ciurana,
Ana1; Vila, Rosa1; Fossas, Pilar2
1
Nursing Department, Hospital de Mataró, Mataró, Spain; 2Department of Neurology,
Hospital de Mataró, Mataró, Spain
Introduction: Oropharyngeal dysphagia (OD) after stroke is underestimated and
underdiagnosed as a cause of major nutritional and respiratory complications. We
aimed to analyze the clinical impact of the diagnosis of OD following nursing
assessment in patients with acute stroke. Material and Methods: 98 patients with stroke
(53% women; 81 years median age) were consecutively admitted to the neurological
unit of the hospital during 7 months. Clinical assessment of OD by the volume-viscosity
swallow test (V-VST), clinical data, stroke type and topography, Barthel Index,
Canadian Neurological Scale and nursing processes during admission were collected.
Results: 93% patients presented an ischemic stroke (51.6% in MCA and 13.3% in
vertebrobasilar territory). Barthel index following admission was 30 and Canadian scale
7. V-VST was performed during the first 24h in 50.8% patients and later in the rest.
61.1% patients presented clinical signs of OD and 56.3% signs of impaired safety. Up
to 15.3% required tube feeding. Nursing procedures following detection of OD were: a)
dietary restrictions (93.2%); adaptation of texture (75%) and bolus volume (83.9%);
use of bedside pictograms (79.7%); weight control (79.9%); b) patient-family
education on OD (84.7%); c) SLP (84.7%) and dietitian consultancy (25.5%); d)
diagnosis of OD in clinical nursing records (100%) and follow-up during admission
(61%). Conclusions: Up to 2/3 patients with acute stroke presented OD and more than
50% signs of impaired safety. Nurses play a major role in the multidisciplinary
dysphagia team by early identification of patients at risk for OD, selection and follow up
of dietary adaptations and care of NG tubes, education of families and monitoring of
patients during admission.
PA.02
Benefits of the implementation of a swallowing test in a stroke
unit .preliminary results.
Sagalés, Maria1; Cocho, Dolores1; Homs, Isabel1; Cobo, Marivi1; Bao, Pilar1; Pou,
Marina1; Mas, Pilar1; Aloy, Andreu1; Melià, Sussagna1; Perez, Gemma1; Pujol, Gemma2;
Sabaté, Rosa2; Serra, Jordi2; Tantiñà, Silvia2
1
Hospital General de Granollers. Pharmacy Department, Granollers, Spain; 2 Hospital
General de Granollers. Department of Nursing
INTRODUCTION In acute stroke, dysphagia is present in almost 30% of patients. Half of
them suffer aspiration, and 4% dies for this motive. The aim of the study was to
analyze the preliminary benefits of the implementation of a swallowing test 2
volumes/3textures (2v/3T) in our Stroke Unit (SU) compared to water test METHODS
We analyzed consecutively and prospectively during 4 years all acute stroke patients
hospitalized in our SU. From 2008 until 2010 the swallowing was evaluated by the
water test (G0) and from 2011 by the test 2v/3T (G1). We analyzed demographic data,
vascular risk factors, etiological subtype according to TOAST criteria, neurological deficit
with NIHS scale, presence of dysphagia, aspiration treated with antibiotic and mortality
rates. RESULTS We analyzed 367 patients with acute stroke (G0 = 275, G1 = 92). We
detected only significant differences between both groups in the percentage of TACI
(16 % G0 vs 45 % G1, p=0.0001) and median in the NIHSS (G0, 4 vs 7 points G1,
p=0.003). We detected a major percentage of dysphagia G0 22%vs 32 % G1 (NS), a
reduction in the mortality 4.4 % G0 vs 1.1 % G1 (NS) and in the aspiration rates 6.3 %
G0 vs 4.9 % G1 (NS). CONCLUSIONS In spite of the major neurological deficit in the G1,
we have detected that the test 2v/3T compared to the water test has allowed us to
diminish the percentage of aspiration in a 1 % and the mortality in 3 % in acute stroke
patients. Possibly with a greater sample of patients the results could be statistically
significant.
PA.03
Evaluation of swallowing function using videofluoroscopy in patients with
spinocerebellar ataxia and complaint oropharyngeal dysphagia
Soria, Franciele1; Furkim, Ana Maria2; Abdulmassih, Edna3; Teive, Helio4; Santos,
Rosane4
1
FAG, Toledo, Brazil; 2UFSC, Florianopolis, Brazil; 3UFPR, Toledo, Brazil; 4UFPR, Curitiba,
Brazil
INTRODUCTION: The spinocerebellar ataxia is a degenerative disease characterized by
motor incoordination, resulting in dysfunction of the central nervous system
(cerebellum). which can cause loss of coordination of voluntary muscle movement,
motor coordination, control of speech, the articulation of words and swallowing. The
objective of this study was evaluate of swallowing function using videofluoroscopy in
patients with spinocerebellar ataxia and complaints of oropharyngeal dysphagia in order:
Assess the severity of dysphagia through the dynamic study of swallowing by
videofluoroscopy. MATERIALS ANS METHODS: The study was conducted at Hospital
Clinics, Federal University of Paraná (HC-UFPR). 30 patients with spinocerebellar ataxia
(SCA) was participated the dynamic evaluation of swallowing by videofluoroscopy. 15
dominant females and 15 males. RESULTS: The study showed the prevalence of oral
dysphagia observed in dynamic evaluation of swallowing by videofluoroscopy. According
to the severity of swallowing proposed by Ott et al., of the 30 patients 24 (80%) had
mild dysphagia, due to uncoordinated oral preparation and chew solid food cake and
pudding consistency, and oral ejection slowed to pharynx. DISCUSSION: WINTER &
JUEL (2003); CORWIN & GIRARDET (2003); LORENZONI et al. (2008) reported that the
loss of nerve function causes structural changes which are caused by lack of nervous
stimulation, not to use the area ffected by immobility, and lack of muscular effort in
these cases is present in muscle weakness and muscle wasting. CONCLUSION: In the
dynamic evaluation of swallowing by videofluoroscopy patients show changes in the oral
phase of swallowing, due to difficulty in movement preparation and chewing of the diets
offered.
PA.04
Taking the history in patients with swallowing disorders: an illustration of the
clinical practice
Otto, Ferdinand; Pokieser, Peter
Medical University of Vienna, Austria, Vienna, Austria
Introduction: The purpose of this study is to assemble the existing concepts of taking a
patients history concerning swallowing disorders. Therefore, a structured interview with
Board members and invited speakers of the ESSD meeting in Leiden in October 2011 is
performed. The intention is, to gain an overview about the existing anamnestic
strategies for swallowing disorders. Material and Methods: A structured, open-ended
interview is performed with 18 participants is performed. The interview form consists of
different types of questions. The questions include factual issues about the interviewee
and his or her general experience and provide information about patient-physician
communication. Three qualitative methods are used in this study (Critical incidence
technique, problem driven analysis and grounded theory). Results: The interviews show
a wide variety of concepts in talking a patient’s history. There is an accordance
regarding the request for general symptoms like dysphagia for solid and liquids,
aspiration and globus sensation. Besides specially designed research questionnaires for
clinical studies nine of 18 interviewees (50%) use clinical questionnaires. The time
exposure for the interview varies from 5 to 45 minutes. Discussion: The anamnestic
concepts for swallowing disorders of experts from several clinical vary widely, but share
the dedication to focus on the specific and individual problem a patient presents. Each
interviewee has its own manner influenced by his clinical background and personal
experience; questionnaires are used occasionally.
PA.05
Dysphagia manageme3nt in the acute phase of stroke
Smithard, David1; Fairfield, Carol2; Roffe, Christine3; Enderby, Pamela4
1
Kent Community Health Trust, Ashford, United Kingdom; 2Reading University, Reading,
United Kingdom; 3Keele University, Keele, United Kingdom; 4Sheffield University,
Sheffield, United Kingdom
Introduction The management of swallowing disorders in the UK is not uniform. The
available evidence base to develop a pathway is small with recent systematic reviews
not providing a clear direction. Methods A questionnaire, enquiring about the type and
timing of assessments and management decisions in the early treatment of dysphagia,
was distributed to attendees at the UKSRG 2012 conference. Results 25 questionnaires
were returned, 20 were sufficiently complete for analysis. All services completed
Dysphagia screening within 24 hours. Many services utilised adjuncts to bedside
assessment such as pulse oximetry (80%) and cervical auscultation (75%).
Videofluoroscopy was available to all services, but with varied frequency of use from
rarely (<10% of cases) to frequently (10-50% cases). Modification of food texture and
liquid thickness was the initial treatment offered, in the first 72 hours, by all services.
Other modification of food and liquid such as ice cool bolus were not routinely offered.
Compensatory postures and specific exercises were evidenced across services with
varying frequency, but some were used by all, such as chin tuck. Access to FEES or
videofluoroscopy was not a predictive factor as to the types of treatments employed,
but access to both was associated with earlier and wider use of swallowing exercises
and compensatory strategies. Access to FEES wasreported as a major potential
determinant in treatment choice. Discussion These results confirm that the
management of dysphagia across the UK is not uniform which is probably due to the
lack of sufficient evidence on to which base practice.
PA.06
Detection of the degree of dysphagia and the level of oral intake in the clinical
evaluation for the risk of dysphagia
Mancopes, Renata; Fávero, Talita; Trindade Gonçalves, Bruna Francieli; Constantino
Drozdz, Daniela Rejane; Mulazani Maria, Camila
Universidade Federal de Santa Maria, Santa Maria, Brazil
Objective: to relate the degree of dysphagia and the level of oral intake through the
clinical evaluation of the risk for dysphagia. Methodology: A cross-sectional analytical
study with retrospective and quantitative approaches. The target population consisted
of all the patient records contained in the database of the Laboratory of Dysphagia in a
University Hospital. Results: 146 subjects, 90 (61.6%) were male. From the total
sample of subjects, 26 (17.8%) had normal swallowing; 63 (43.1%) had functional
swallowing; 27 (18.4%) had mild dysphagia; 7 (4.7%) with mild to moderate dysphagia;
5 (3.4%) with moderate dysphagia; 3 (2.0%) with moderate to severe dysphagia and
15 (10.2%) with severe dysphagia. Regarding the level of oral intake, according to the
Functional Oral Intake Scale (FOIS), 22 patients (15.0%) presented level 1; 37 (25.3%)
presented 2; 23 (15.7 %) were classified as level 3; 3 (2.0%) as level 4; 5 (3.4%) as
level 5; 3 (2.0%) as level 6 and 40 (27.3%) as level 7. Still, 17 patients (11.6%)
classified as FOIS 1, obtained moderate to severe or severe degrees of dysphagia, and
37 patients (25.3%) FOIS 7 were classified as having normal or functional swallowing.
Conclusion: It was observed correlation between the degree of dysphagia and the level
of oral intake. The data indicate the reliability of the joint use of these tools to establish
the parameters associated with swallowing, in order to verify the actual conditions of
feeding and possible damages caused to the patient's overall clinical status.
PA.07
Protocol to patients with neurogenic dysphagia.improving safety
Martínez Serrano, Luz
Instituto de Enferemedades Neurológicas, Guadalajara, Spain
Introduction: The presence of dysphagia has been associated with an increased risk of
pulmonary complications and even mortality. Early diagnosis of the detection of
dysphagia in patients, who suffered stroke, may reduce these complications, and
hospitalization time. Objectives - Conducting early detection of dysphagia. - Evaluating
and taking approaches to improve swallowing efficiency and safety. - Minimising the
risk of malnutrition, dehydration and respiratory complications. - Increasing the quality
of life of the patients. Materials and methods: Descriptive study protocol for patients
with neurogenic dysphagia which provides on-going training to staff, assessed with
MECV-V, pursuing the development of individualised treatment. Hospital diet is adapted
to improve swallowing safety and efficiency of patients included in the protocol together
with implementing patient’s identification tools. A multidisciplinary team is needed
couple with protocol inclusion within the committee on nutrition and ACVAs to monitor
diets and data collection. Results and discussion: Patients suffering from stroke in the
years 2010 and 2011 were studied. The results showed a high percentage of patients
with functional dependence, cognitive impairment and aphasia, which brought
difficulties in the implementation of the protocol. 98.6% and 99.8% of the patients in
the years 2010 and 2011 respectively were diagnosed with moderate to severe
dysphagia. Following implementation of the protocol discharge rates were reduced to
41.24% and 29.7% respectively. There was statically significant improvement in
patients that were included in the protocol in both years. Safety and efficiency in
swallowing was achieved, therefore reducing the chance of respiratory complications.
PA.08
Clinical evaluation of swallowing in patients with stroke in the emergency
room
Soria, Franciele1; Furkim, Ana Maria2; Nunes, Maria Cristina3; Albini, Rejane3; Macri,
Marina3; Pinto, Gisele3; Lange, Marcos4
1
Faculdade Assis Gurgacz, Toledo, Brazil; 2UFSC, Florianopolis, Brazil; 3UTP, Curitiba,
Brazil; 4UFPR, Curitiba, Brazil
INTRODUCTION: The Glasgow Coma Scale (GCS), (TEASDALE & JENNETT, 1974) is
used in critically ill patients with severe central nervous system to assess the level of
consciousness. Clinical markers for monitoring the evolution of oral were proposed by
the use of Functional Scale Oral Ingestion (FOIS®), (CRARY, MANN & GROHER, 2005).
The objective of this study is correlate with the ECG and swallowing FOIS® in patients
affected by stroke in the emergency department (ED). MATERIALS AND METHODS: A
prospective descriptive study at the Clinical Hospital of Paraná with 30 patients with
acute stroke, 18 (60.0%) were female and 12 (40.0%) were male with ages ranging
from 30 to 86 years. Patients were recruited at the time of hospital admission in ED for
the collection of data, evaluation of two health professionals - nurses and speech
therapists in the application of ECG, clinical evaluation of swallowing function and
application of FOIS®. RESULTS: In the application of ECG in 21 (70.0%) patients
showed the highest score between 13 and 15. In the clinical evaluation of swallowing
function prevailed the capture efficiency of the cake, labial and preparation of the cake
and no extraoral later in the exhaust, the waste in the oral cavity, the cough reflex and
in hawks. Of the 30, 20 (65.5%) were found at level 7 in accordance with the scale of
FOIS®. DISCUSSION: The multidisciplinary team faces challenge in PA hospitals and
the care of stroke (ALVES & KOIZUMI, 1999). There is a significant correlation between
the values of ECG and FOIS®.
PA.09
Implantation of a risk assessment protocol for laryngotracheal aspiration
Borges de Oliveira, Maria Cristina; Fortes Ferreira, Dario; Pagliotto da Silva, Amanda;
Cristina Pires, Elaine
Rede D'Or São Luiz S/A - Unidade Morumbi, São Paulo, Brazil
INTRODUCTION: Safe and effective management of swallowing done by
multidisciplinary team prevents and reduces risk of clinical complication due to
laryngotracheal aspiration. In Rede D’Or São Luiz S/A – Morumbi unit, prevalent
dysphagia is of 24.2 cases per one thousand. The “Microaspiration Clinical Protocol” was
created considering these data and risk factors for oropharyngeal aspiration. OBJECTIVE:
Implantation of a protocol of identification of the risk of laryngotracheal aspiration by
the multidisciplinary team in adult patients admitted to the institution. METHODOLOGY:
During admission of the patient, nurses will apply the multiprofessional risk assessment.
For the duration of the laryngotracheal aspiration risk, the protocol and preventive
measures such as changes in the consistency of the food and the formalization by
means of medical prescription of the speech therapist’s assessment will be instituted.
Depending on the assessment, the speech therapist will suggest rehabilitation and/or
management of the path, consistency and fractioning of the diet, besides orientations to
the multiprofessional team and family. The protocol also involves the physician
responsible for nutrition, responsible for the assessment and prescription of entereal or
paraentereal diet, the nutritionist, responsible for the nutritional risk assessment and
adaptation of the consistency of the food according to the speech therapist’s
prescription and the physiotherapist, responsible for managing the pulmonary situation
and possible intercurrents. From the implantation of the protocol the Incidence of
Laryngotracheal Aspiration in risk patients / day will be measured, with a target of
reducing it in 50% in six months. The data will be analyzed descriptively and
analytically.
PA.10
Prevalence of dysphagia and malnutrition risk in a ‘fragile patient hospital
unit
Muñoz de Escalona, Teodosia; Uroz, A.; Garrido Fernandez, P.
Unidad de Nutrición Clínica y Unidad de Paciente Frágil,, Almeria, Spain
Background: Dysphagia is a symptom whose prevalence can range from 30% to 84%
depending on the pathology. It is related to higher disability, more malnutrition, longer
hospital stay and higher mortality. The aims of this study were to determine the
prevalence of dysphagia and malnutrition risk in a fragile patient hospital unit, using
validated tools to evaluate dysphagia EATING ASSESMENT TOOL-10 (EAT-10) and the
nutritional screening tool Nutrition Risk Screening 2002 (NRS-2002), and to establish
corrective actions. Methods: We evaluated 51 patients, 26 female (51%) and 25 male
(49%). Medium age was 77,53 (from 30 to 98). Dysphagia grade was determined using
the EAT-10 , a 10 question questionnaire (each scored from 0 to 4). If final score was
≥3, dysphagia may be present. The malnutrition screening tool used in this essay was
the NRS-2002, which is based on Body Mass Index, weigh loss, food intake diminution
and disease severity. Results: Prevalence of dysphagia was 70% (mean= 12,57;
range=8,99-16,14). 80,6% of patients with dysphagia had nutritional risk;
notwithstanding, just 26,7% of non-dysphagia patients had nutritional risk. The
disagreement between the results is statistically significant from p≤0,001 (χ² test ,
Yates correction for continuity) Discussion: Current prevalence of dysphagia in a ‘fragile
patient hospital unit’ ,nutritional risk and hospital complications prediction are high.
EAT-10 is an useful, easy and fast dysphagia detecting scale which could help to avoid
malnutrition and other associated problems.
PA.11
Suprahyoid muscles activity of maximum jaw opening and swallowing in
healthy young people
Wada, Satoko; Tohara, Haruka
Department of Dysphagia Rehabilitation, Nihon University School of Dentistry, Chiyoda,
Japan
Introduction: We developed a jaw opening exercise as suprahyoid muscles training for
laryngeal elevation, since some suprahyoid muscles are involved in jaw opening
muscles. And our past study revealed this exercise was effective for hyoid elevation and
upper esophageal sphincter opening. Although we thought this exercise strengthened
suprahyoid muscles, muscle activity have never been investigated. Therefore, we
compared the amount of muscle activity of suprahyoid muscles during swallowing and
maximum jaw opening to know the basical relationship of them. Methods: Subjects
were 12 healthy young people (five men, seven woman; average age, 30.08}4.14
years; agerange, 26-40 years). The surface electrodes were put along to geniohyoid
muscle, and electromyogram of saliva swallowing and three seconds of maximum jaw
opening were recorded for three times respectively. Average of Root mean square (RMS)
of each EMG data was analyzed. Results: Average RMS at maximum jaw opening and
swallowing were 13.91}6.77 and 5.21}2.34 respectively, and RMS at maximum jaw
opening was significantly larger than RMS of swallowing (p<0.01). In addition,
correlation coefficient was considerably large (r=0.95, p<0.01), and percentage of RMS
at swallowing was 39.03}7.95% of RMS at maximum jaw opening. Discussion: The
relationship of suprahyoid muscles activity between maximum jaw opening and
swallowing was considerably high in healthy young people. And the amount of muscle
activity when swallowing was about 40 percent of that at maximum jaw opening.
Further, same protocol should be performed before and after the exercise to examine
the effect of the jaw opening exercise on muscle activity.
PA.12
Relationship between aspiration pneumonia and tracheal aspiration
Soria, Franciele1; Furkim, Ana Maria2; Lagos, Hellen3; Hirata, Gisela3; Santos, Rosane3;
Celli, Adriane3; Abdulmassih, Edna3
1
FAG, Toledo, Brazil; 2UFSC, Florianopolis, Brazil; 3UTP, Curitiba, Brazil
Introduction: Patients with dysphagia are at risk tracheal aspiration, ie, presence of
food and / or fluids below the vocal folds entering the airways, increasing the risk of
pneumonia and associated problems. Langmore (1999) understands that there are
three requirements for the development of aspiration pneumonia: a) pathogenic germ
present in the material to be aspirated; b) the material must be aspirated and c) the
lungs must be unable to resist pathogens. The objective of this study was to verify
tracheal aspiration by videofluoroscopy in children with and without recurrent
pneumonia condition. Methods and Materials: Retrospective observational study
through analysis of videofluoroscopy swallowing study and correlation with history of
pneumonia referred by caregivers. It was reviewed swallowing studies of 71 children
with cerebral palsy, between 0 and 14 years of age, performed at the Clinical Hospital
of Paraná, between the years 2008 and 2011. Results: From total of 71 swallowing
studies and medical histories analyzed, 19 referred history of previous pneumonia, of
which 11 (57.9%) had tracheal aspiration of at least one consistency and 8 (42.1%) did
not show tracheal aspiration . Out of 52 case histories without reference to previous
history of pneumonia, it was found that 38 (73.1%) children did not have tracheal
aspiration and 14 (26.9%) had tracheal aspiration of at least one consistency.
Conclusion: pneumonia previous history should not be the only criterion to presume
tracheal aspiration and the presence of tracheal aspiration can not be regarded as the
major cause of pneumonia in this population.
PA.14
Dysphagia in scleromyositis - case report
Silva, Marta;
Centro Hospitalar do Porto, Porto, Portugal
Background: Scleromyositis is a rare disease that is characterized by the coexistence of
inflammatory myositis and systemic sclerosis (scleroderma. There is a lack of research
on studies about dysphagia in scleromyositis. In myositis, dysphagia is found in 10-30%
of the cases, due to the weakness of both oropharyngeal muscle and upper third of the
esophagus. In turn, in scleroderma the swallowing problems are focused on the oral
and pharyngeal phases, namely in the food processing stage and in the food bolus
transit. These problems occur as a result of loss of peristaltic movements, reduced
muscle strength, laryngeal and pharyngeal muscle stiffness, including the upper
esophageal sphincter. The purpose of the present study is to describe the evaluation,
treatment and evolution of a Scleromyositis case, with severe oropharyngeal dysphagia.
Case Report: Fifty-eight year-old female, with about a year of clinical progression of
muscle weakness and dysphagia. The clinical evaluation and the video fluoroscopy
showed microstomia, deficits in the preparation and oral ejection, as a result of facial
and tongue muscle stiffness; nasal regurgitation, absence in the elevation of the larynx
and aspiration for all consistencies, without cough reflex. In FOIS scored 0 – nothing by
mouth. Results: After 9 months of intensive therapy it was reached level 5 of FOIS.
Discussion: The isotonic exercises program and stretching of the oral structures,
laryngeal manipulation, vocal exercises to increase strength, laryngeal flexibility and
mobility, Shaker exercise and voluntary swallowing maneuvers were beneficial to the
recovery of oral intake and removal of PEG.
PA.15
Speech therapy criteria for tracheal decannulation in traumatic brain injury
patients.
Soria, Franciele1; Furkim, Ana Maria2; Santos, Rosane3; Zanata, Isabel3; Hirata, Gisale3
1
FAG, Toleda, Brazil; 2UFSC, Florianopolis, Brazil; 3UTP, Curitiba, Brazil
INTRODUCTION: Swallowing difficulties in Traumatic Brain Injury (TBI) patients are
influenced by several aspects, including the use of tracheostomy. It is known that
tracheostomy has an impact on swallowing. However, few studies exist which specify
the following criteria at the time of tracheal decannulation. The objective of this study
was establish speech therapy criteria for tracheal decannulation in TBI patients.
MATERIALS AND METHODS: 20 patients with confirmed diagnosis of TBI,
tracheostomized with opened tube, underwent an evaluation following tracheal
decannulation criteria through a clinical assessment protocol. Several variables were
considered: age, sex, diagnosis and anatomic region of injury and it were observed six
criteria for tracheal decannulation. RESULTS: decannulation was performed in 12 (60%)
patients. 14 (70%) had a score greater than 8 on Glasgow Scale and only 2 (14%) of
these could not be decannulated. 12 (60%) of patients maintained breathing pattern as
for the closure of the tube and could be decannulated. Of 20 patients evaluated, 11
(55%) showed no suggestive signs of aspiration and of these, 9 (82%) began occlusion
training of the tube. DISCUSSION: The speech-language criteria were relevant to
establish the beginning of the tracheostomy decannulation process. Speech- language
clinical assessment should focus on the patient's condition as for having an early
tracheal decannulation, avoiding the impact of tracheostomy. CONCLUSION: This study
allowed us to establish six speech-language criteria for tracheal decannulation: level of
consciousness, respiration, orotracheal secretions, cough, speech and swallowing.
PA.16
Dysphagia in adult congenital myopathy: characteristics, management, and
outcome
Hill, Fiona
Tallaght Hospital, Dublin, Ireland
Introduction
To report on the nature of dysphagia, dysphagia management and outcomes in an adult
case of rare congenital myopathy.
Method
A 32 year old woman with Actin Myopathy was referred to Speech & Language Therapy
for swallow evaluation. She was referred from a Neurology outpatient clinic with a 4
month history of a tender and painful lump in her throat and pain on swallowing.
Swallow assessment included interview on swallowing history, clinical bedside swallow
evaluation, and initial videofluoroscopy examination. A 10 week period of dysphagia
intervention focusing on rehabilitation and compensation was followed by a repeat
videofluoroscopy evaluation of swallowing. Outcome measures utilised included client
report, swallow parameters, and published dysphagia scales.
Results
Symptoms of oral and pharyngeal dysphagia were detected on interview and clinical
swallow evaluation, and mild-moderate dysphagia confirmed on videofluoroscopy
examination. Characteristics included sensation of pressure on swallowing, piecemeal
deglutition, tongue weakness, tongue base impairment, weak pharyngeal constrictors
and pharyngeal residue. Symptoms of oesophageal dysphagia were also evident on
videofluoroscopy. Repeat evaluation of swallowing following a 10 week swallow
rehabilitation programme revealed improvement in dysphagia symptoms.
Discussion
Management of dysphagia in congenital myopathy requires the utilisation of a
combination of assessment methods, clinical awareness and skill to enable not only
timely and accurate diagnosis of potential oral, pharyngeal and oesophageal phase
disorders, but also appropriate intervention, of which swallow rehabilitation should be a
consideration.
PA.17
Dysphagia in huntington disease: a proposal for speech therapy
Montagut Colomer, Núria; Molinuevo, José Luis; Barreiro, Soledad; Gazulla, Dolores;
Muñoz, Esteban
Hospital Clinic, Barcelona, Spain
INTRODUCTION: Huntington’s disease (HD) is a progressive neurodegenerative
autosomal dominant disease characterized by motor, behavioural and cognitive
disturbances. Dysphagia is a common and life threatening symptom of the disease. Our
objective was to study the swallowing dysfunction occurring during the oral and
pharyngeal phases and to present a specific work program to improve dysphagia.
MATERIALS AND METHODS: We assessed the effectiveness and safety of the oral and
pharyngeal phases in 10 ambulatory HD patients through the Method of Clinical
Examinations of Viscosities and Volumes. In addition, we performed a clinical
assessment of voluntary movements of the lips, tongue and soft palate. We designed a
rehabilitation work program according to our results. RESULTS: Patients were between
46 and 79 years-old. The Independence Scale ranged 55 to 75%. In the oral phase, we
observed ineffective lip closure in 6 patients, oral residue in 4 and repetitive swallows in
10. In the pharyngeal phase there was pharyngeal residue in 7 patients, cough in 3,
voice changes in 6, and a drop of 2 points in the blood oxygen saturation in other 3.
Accordingly to our findings we propose a rehabilitation program including lips and
tongue praxis, postural strategies, specific supraglotic manoeuvre and changes in the
volume and viscosity of the bolus. DISCUSSION: The oral and pharyngeal swallowing
phases are already compromised in HD moderate stage. We hypothesise that a specific
rehabilitation program of dysphagia may improve swallowing difficulties in HD and
contribute to maintain their nutritional status.
PA.18
Psychogenic dysphagia
Demýr, Numan; Serel, Selen; Karaduman, A. AyÞe
Hacettepe University, Ankara, Turkey
INTRODUCTION: The purpose of this study is to determine the relationship between the
symptoms of the patients who had psychogenic dysphagia and their videofluoroscopic
swallowing study findings. MATERÝAL AND METHODS: 34 patients whose mean age was
30,79±7,7 years were included. Their swallowing symptoms were noted.
Videofluoroscopic swallowing study with liquid, puding and biscuit consistencies was
done. RESULTS: 82,4% of the patients had a fear, depression or sadness history before
their swallowing problems. After these events their swallowing problems started and
gradually increased. They described feeling stuck when eating,especially with solid
foods. In videofluoroscopy, 50% of cases in liquids, 61,8% of cases in pudding
consistency, 79,4% of cases in biscuit consistency had prolonged oral transit time.
There was no correlation between the area which they had feeling stuck and the area
which residue was seen in videofluoroscopy. There were no penetration and aspiration.
Only 3 of them had reflux symptoms. DISCUSSION: Swallowing disorders can
determine with detailed story taken and clinical follow-up. But videofluoroscopic
swallowing studies are very important to give precise information. So in psychogenic
dysphagia, videofluoroscopy can be used for both evaluation and biofeedback.
PA.19
Dysphagia after treatment of descending necrotinzing mediastinitis
Nagai, Miki
Osaka General Medical Centre, Osaka, Japan
The aim of this study is to investigate about oropharyngeal dysphagia after treatment of
descending necrotizing mediastinitis (DNM).DNM is severe inflammatory disease arising
from tonsillitis or dental infection with deep neck abcess and its fatality rate is from6.5
to25“.And We experienced 3 cases of DNM.Main symptons for long hospitalization after
DNM were difficulties in swallowing of solid-food bolus and aspiration.We present 3
cases and discuss about dysphagia after treatment of DNM. Case1:The patient was a
76-year-old male. Case2: The patient was a 51-year-old male .Case3: The patient was
a 55-year-old male.TheyThey had undergone debridement ,surgical drainage and
tracheostomy for DNM.They had severe dysphagis after therapy for DNM.
PB.01
Clinical swallowing evaluation of dementia of the alzheimer type (dat) in
different stages of disease severity
Vanderwegen, Jan1; Van Vlasselaer, Kristin2
1
CHU Saint-Pierre, Brussels, Belgium; 2Imelda ziekenhuis, Bonheiden, Belgium
Introduction This study determined type and incidence of eating disorders and
dysphagia in end-stage dementia patients using several evaluation scales. Methods 15
patients in a major psychogeriatric hospital were identified with probable DAT using the
Global Deterioration Scale (GDS), Mini Mental State Examination (MMSE) and
neuropsychiatric diagnosis conform DSM-IV-criteria. Exclusion criteria were an
abnormal recent CAT-scan of the brain and/or if other psychiatric, neurological or
surgical pathology were suspected. All patients (mean age = 85 yo; mean MMSE = 9)
were assessed by non-interactive observation of a typical lunch with respect to daily
routine. Observation and dysphagia scales were scored and correlated with results of a
comprehensive clinical swallowing evaluation. Results Type of problems were related to
GDS. Mildl DAT showed feeding difficulties with prolonged eating duration, need of
prompting, and mealtime assistance due to apraxia for utensils. Moderate DAT showed
additional oral phase dysphagia with oral residue, inadequate chewing and prolonged
oral transportation time. Severe DAT showed increasing eating disorders with total
feeding dependence and food refusal; oral phase dysphagia with absent or continuous
chewing, biting reflexes, loss of food from the oral cavity and extensive oral residue;
pharyngeal phase dysphagia consisted of delayed swallowing initiation, wet voice,
coughing, multiple swallows and pneumonia. Discussion Deteriorating DAT showed
progression of feeding disorders and dysphagia. Initial problems with self-feeding
presents without clear dysphagia. Moderate to severe DAT necessitates increased
feeding assistance and needs evaluation for oral stage disorders. Severe DAT needs
FEES due to the possibility of severe pharyngeal dysphagia.
PB.02
Evaluation of quality of life in patients with stroke and dysphagia
Silveira Santos, Rafaela; Miranda, Rúbia; Pacheco, Aline; Dantas, Roberto; Pontes-Neto,
Octavio
USP, Ribeirão Preto, Brazil
Introduction: Subjects with dysphagia may show losses in nutritional aspects and
pulmonary status and, moreover, has the most basic of social functions affected: the
ability of to eat and drink. This restriction faced by the patients in their day to day may
bring up feelings as frustration, discouragement, shame and constraint which can
produce variable impact on their quality of life. In this context, the aim of this study
was to evaluate the quality of life of patients with stroke and dysphagia. Method:
According to inclusion and exclusion criteria,we included in the research patients with
diagnosis of stroke confirmed by brain imaging examinations admitted to a tertiary
university hospital from August 2011 to January 2012 who had dysphagia.The Quality
of life in Swallowing Disorders (SWAL-QOL) survey was applied in all selected patients,
one mouth after stroke, in order to evaluate their quality of life. It was evaluated 11
domains, each classified 0-100, and the closer to 100, the lower the quality of life.
Results: Twenty seven patients participated in the study. In the sample, the score
average of each domain was: sleep (52,2), eating desire(69,1), eating duration (71,2),
fadigue (73,7), fear (78,4), communication (81,4), food selection (84,2), symptoms
(86,9), burden (88,4), social functioning (91,1) and psychological distress (91,8).
Discussion: Patients with stroke and dysphagia have swallowing difficulties that affect
their quality of life, mainly causing fear and unwillingness to eat. Therefore, studies to
better evaluate the quality of life of such patients are necessary.
PB.03
Comparison of clinical examination and fiberoptic endoscopic evaluation of
swallowing in parkinson’s disease
Busch, Roberta
Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
INTRODUCTION: The Parkinon’s disease can present dysphagia and increased morbidity,
mortality in the patients. Many have silent saliva aspiration and/ or food and may not
have the complaint. These symptoms can be difficult to detect by clinical assessment
and cervical auscultation. The aim of the study is to compare clinical examination and
fiberoptic endoscopic evaluation of swallowing (FEES). MATERIAL AND METHODS: We
analyzed medical records of 49 patients with Parkinson's disease, 30 men and 19
women, and considered the clinical signs of aspiration, cough and voice change after
swallow in the clinical trial (CT). By (FESS) analyzed data from tracheal aspiration and
food stasis. RESULTS: Thirty-nine subjects complained of swallowing. In the clinical trial
14 showed signs of cervical auscultation and aspiration for 13 cough or voice change
after swallow and FEES, 12 confirmed tracheal aspiration and 26 had stasis. Of all
patients analyzed 9 patients did not complain though, the four had CT signs of
aspiration for cervical auscultation and four of them, coughing or voice change; in FEES,
7 and 26 had aspiration stasis. These data are statistically analyzed. DISCUSSION:
Detection of aspiration appeared to be more sensitive than clinical test with cervical
auscultation performed by an experienced professional. As for the stasis were not
detectable in the clinical examination. Therefore, the FEES can be of great importance
for the evaluation of patients with Parkinson's disease, since the rigidity of the posterior
pharyngeal wall and muscle cricopharyngeal may be the cause of stasis and aspirations
after the pharyngeal phase.
PB.04
Dysphagia severity and vital capacity in healthy elderly individuals
Takaya Paiva, Cora Sofia1; Tiemi Mituut, Cláudia1; Alves da Silva, Marcela Maria1; Totta,
Tatiane2; Figueiredo Magalhães, Fabiani2; Ghedini Brasolotto, Alcione1; Berretin-Félix,
Giédre1
1
Universidade de São Paulo- USP, Bauru, Brazil; 2Hospital for Rehabilitation of
Craniofacial Anomalies, Bauru, Brazil
Purpose: The coordination between swallowing and breathing is essential to an
adequate pharyngeal phase and airway protection. It´s important to the safety and
effectiveness of the swallowing process. There are few studies that approach the
relation between pulmonary function and presbyphagia or oropharyngeal dysphagia.
The objective of this study was verify if the maximum capacity expiratory has relation
to the dysphagia severity in elderly individuals. Methods: 23 healthy elderly, no
smoking, with age between 60 and 82 years (average of 68 years), 11 men and 12
women. The dysphagia severity was classified using the Dysphagia Outcome and
Severity Scale (DOSS) after the endoscopic evaluation. The vital capacity was evaluated
using the spirometry. Results: 8,7% of the individuals presented normal swallowing,
73,9% presented functional swallowing and 17,4% presented mild dysphagia. Only 30,4%
of the individuals presented less results in the vital capacity when compared with the
normal standard. No statistically significant correlation was found between the
conditions, according to Spearman test (p=0,34). Conclusion: No relation was observed
between pulmonary capacity and dysphagia severity in healthy elderly individuals.
Future studies are necessary with individuals with higher dysphagia severity.
PB.05
Clinical value of fiberoptic endoscopic evaluation of swallowing (fees) in
patients with varying degrees of dementia of the alzheimer type (dat)
Vanderwegen, Jan
CHU Saint-Pierre, Brussels, Belgium
Introduction DAT is associated with multiple feeding disorders, mainly in the
preparation and oral stage. Laryngopharyngeal dysphagia has not been studied to a
great extent. This study aimed to determine laryngopharyngeal signs associated with
dysphagia using FEES. Methods 75 DAT patients in a major psychogeriatric long-term
care facility were studied. Inclusion criteria were signs of dysphagia on clinical
swallowing examination (CSE), recurrent pneumonia or unexplained weight loss.
Exclusion criteria were history of stroke and surgical pathology. All patients (mean age
= 83 yo; mean MMSE = 9) were assessed using a diet typical for the patient. FEES
results were correlated with the results of a comprehensive CSE and the degree of
dementia. Results Initial stages of DAT were not associated with typical findings on
FEES. Mild and severe stages 560 patients) revealed abnormalities in different
swallowing phases. Preparation showed inadequate mastication and oral preparation
resulting in excessive bolus loss before the swallow. Laryngeal movements were
unaffected but slow and laryngeal sensation seemed to be diminished in severe DAT.
Initiation of the swallow showed excessive delay (defined as > 10 sec.) and a high
amount of residue after the swallow. 30 patients with mild and severe DAT showed
penetration, with 12 patients aspirating and 8 patients showing silent aspiration.
Discussion FEES in DAT patients is not only feasible, it also has a high clinical value.
Therapeutic measures can be evaluated during FEES and mostly consist of diet and
bolus modification to allow maximum and safe oral intake in this fragile patient group.
PB.06
Characterization of the level of oral intake in cva through speech pathology
evaluation
Mancopes, Renata; Mello, Fernanda; Dorneles Bilheri, Diego Fernando; Costa, Cintia
Conceição
Universidade Federal de Santa Maria, Santa Maria, Brazil
Introduction: Dysphagia results of different etiologies, among them the cerebrovascular
accident (CVA), which can imply in food entering air routes, resulting in cough,
asphyxia, pulmonary problems and aspiration, as well as it can generate nutritional
deficits and pneumonia which may lead to death. The Functional Oral Intake Scale
(FOIS) is used to graduate in specific levels the amount of oral intake of food and
liquids. Objective: to characterize the level of oral intake in CVA through speech therapy
evaluation. Material and methods.A cross-sectional analytical study with retrospective
and quantitative approaches. The target population consisted of records of 15 patients
with dysphagia due to CVA, kept in the database of the Laboratory of Dysphagia in a
University Hospital. The evaluation of swallowing was held in accordance to the
proposed on the Protocol of Evaluation of Risks to Dysphagia. To assess the level of oral
intake it was used the FOIS. Results: Out of the 15 patients evaluated, 13% had Level
1; 20% level 2; 7% level 3; 20% level 5; 13% level 6 and; 27% patients had level
7.Discussion: The results showed that 60% of patients had conditions to undergo a total
oral ingestion diet, without the need of an alternative feeding route, although initially
they needed phonoaudiological assistance. It is noteworthy that the speech evaluation
is performed when the patient's clinical status is stable. Although the reduced level of
oral intake and the necessity of an alternative feeding route has been less prevalent in
this sample, the clinical phonoaudiological evaluation is important once the speech
therapist acts with the goal of preventing and reducing complications, starting with the
management of swallowing in a safe and effective way.
PB.07
Screening dysphagia in parkinson’s desease.comparative study in two stages
of evolution.
Rion, Olga; Garnica, Almudena; Roquer, Esther
Hospital Universitari St Joan de Reus, Reus, Spain
INTRODUCTION Characteristics of swallowing disorders in Parkinson’s disease, are very
illustrated in the literature, the prevalence of dysphagia varies from 52% to 82% and
up to 15% of patients have silent aspiration and do not complain of dysphagia.
MATERIALS AND METHODS We employed “MECV-V” by Pere Clavé et al. (volumeviscosity swallow test) to explore 20 subjects with Parkinson’s disease in two stages of
evolution, in a range period of 3 years during their assistance to a multidisciplinary
rehabilitation program . Patients were divided in two subgroups: high (n=7) and low
(n=13) functional dependency. We present the comparative results of the disease
severity based on the Hoehn and Yahr scale, the UPDRS scale, the cognitive space-time
orientation, the signs of impaired detected by patients and the signs of impaired safety
and efficacy.
RESULTS Our results show that nearly 50% of patients are not aware about swallowing
disorders. 15 of 20 patients have signs of impaired safety (10/13 low functional
dependency patients + 5/7 high functional dependency patients) and all of them have
signs of impaired efficacy. In the second exploration 16/20 patients have signs of
impaired safety (11/13 + 5/7) and again all of them have signs of impaired efficacy .
DISCUSSION It is need to raise awareness among Parkinson’s disease patients that
swallowing disorders can appear during the evolution of the disease, and to learn how
to detect them. From Stages II of Hoehn Yahr begin to predominate signs of impaired
efficacy when we increase viscosity. In second exploration, test begins to show signs of
impaired with lower volumes than in the first time. It is necessary to repeat swallow
test because of the characteristics of the degenerative disease.
PB.08
Eating and swallowing problems in nursing home residents and the access to
therapy support
Smithard, David1; Gill, Lyndsey1; Walker, Margaret2; Soliman, Mohamed3
1
Kent Community Health Trust, Ashford, United Kingdom; 2ARCOS, Malvern, United
Kingdom; 3Luton and Bedford PCT, Bedford, United Kingdom
Introduction: The occurrence of swallowing and eating problems has been reported as
being high in residents of Nursing Homes (NH). Methods: A Questionnaire was sent to
managers of 474 NHs the South East and Midlands, enquiring as to the reasons for
admission, the frequency of neurological diagnosis, frequency of swallowing and eating
(preparing food on the plate and getting it to the mouth) problems present in the
residents and the access to Speech and Language Therapy (SLT), Occupational
Therapy(OT), Physiotherapy(PT) and Dietetics(DT). Results: 209 (44%) NH responded.
There were 5678 residents, 72.4% females; 64.1% were resident because of general
frailty. The commonest neurological diagnosis was Dementia (24.9%) then Stroke
(20.7%). 36.3% had problems with posture. 36.4% required food to be cut up, 30.3%
needed help to feed themselves, 46.9% modified diet and 10% took longer than 40
minutes to eat their food. 69%(SLT), 45%(OT), 47%(PT), and 61% (DT) reviews were
available within 4 weeks, 12%(SLT), 21%(OT), 19%(PT) and 17%(DT) later than 4
weeks. The availability of services was unknown by 20% (SLT), 33%(OT), 25%(PT) and
21%(DT). Discussion: Eating problems and swallowing problems are common. Problems
with posture, help required to eat, taking a long time to eat and coughing/ choking
when eating are indicators aspiration. The availability of services was not known by a
significant proportion of NHs and a significant number of services were slow in
responding. Future studies are required to investigate the clinical effects of these
reported problems and the possibilities of interventions to reduce the risk of aspiration
and associated morbidity.
PB.09
Prevalence and impact of oropharyngeal dysphagia in a medium to long stay
hospital unit
Ros, Rosalia1; Alvarez, Antonio2; Rubio, Cecilia2; Duarte, Enrique2; Antolin, Marta2;
Úbeda, Amparo2; Merino, Francisco2
1
La Fe Universitary and Politechnic Hospital, Valence, Spain; 2La Fe Universitary and
Politechnic Hospital, Valencia, Spain
OBJECTIVES This study aims to study Oropharyngeal Dysphagia (OPD) in patients
admitted in the Medium to Long Stay Unit of an universitary hospital. We evaluated its
possible relationship with potential etiological factors such as cognitive impairment,
disorders in oral health and sarcopenia and with consequences such as malnutrition or
aspirative pneumonia (AP). MATERIAL AND METHOD Descriptive, cross-sectional and
observational study including 81 patients. General data (age, sex, stay length...),
comorbidity (Charlson), cognitive impairment (Pfeiffer), functional status (Barthel),
presence of AP and malnutrition (Mini Nutritional Assessment) were recorded. OPD was
evaluated by the EAT-10 screening test and the volume-viscosity test (V-VST). The
quality of life associated with oral-dental greeting was studied by the GOHAI index. The
presence of sarcopenia was studied by a bioelectrical impedance analysis, manual
dynamometry and physical performance tests. RESULTS The mean age was 78.5 years
(SD12.8), 51.9% were men; 60.5% of them had comorbidity. Barthel index showed
67,5% of patients having severe or total dependence; 33.3% had mild to severe
cognitive impairment (Pfeiffer). EAT-10 was positive in 37% of patients, and V-VST was
pathologic in 46%. There was an impact in the life quality of all patients, GOHAI mean
44,2 (SD 4,4). DISCUSSION OPD was highly prevalent. EAT 10 was not reliable in our
setting as a screening method, probably because of the cognitive impairment of our
patients. The V-VST was a useful way for the diagnosis of dysphagia. A relationship
between OPD and age, mental decline and functional status was found; this could be
explained in terms of causality. It was related too with malnutrition althought not with
other possible consequences as AP.
PB.10
Dysphagia among patient’s with parkinson’s disease
S Queija, Débora1; C Anacleto, Andrea1; G Portas, Juliana2; S Ferreira, Alessandra3; A F
Castro, Mario1; G Pfutzenreiter, Élio1; P Bohn, Nathaniele1; A Dedivitis, Rogério4
1
School of Medical Sciences Centro Universitário Lusíadas and Service of Head and Neck
Surgery, Hospital Ana Costa, Santos, Brazil; 2Barretos Cancer Hospital, Santos,
Brazil;32- School of Medical Sciences Centro Universitário Lusíadas and Service of Head
and Neck Surgery, Hospital Ana Costa, Santos, Brazil; 4Department of Head and Neck
Surgery Hospital das Clínicas, Santos, Brazil
Introduction: Parkinson's disease (PD) is a progressive neurodegenerative condition
characterized by tremor, rigidity, postural instability and bradykinesia. From 70 to 92%
of such patients evolve with tongue, larynx and pharynx involvement. Objective: To
evaluate the swallowing manifestations of PD. Methods: A prospective study evaluating
18 patients with PD was carried. The average age was 68.5. The disease severity was
evaluated according to the Degree of Disability Scale (HY). The patients were evaluated
through videolaryngostroboscopy and dysphagia through the SWAL-QOL (Quality of Life
in Swallowing Disorders). Results: Clinical complaints were referred to by 13 patients
and the most frequent laryngoscopic finding was the laryngeal tremor (83.33%). It was
found that four patients showing arching vocals. In relation to the closing stage, nine
patients showing closing predominantly in open phase. Was identified the presence of
mucus later in two patients and a ball of mucus in a patient respectively. The quality of
life related to dysphagia showed higher impact among patients carrying severe
handicap, mainly on communication, burden, food selection, sleep and eating duration
domains. Discussion: Complaint of dysphagia was referred to by 72% of patients and in
laryngoscopic changes were observed in 94.44%, being the most common finding
dysphonia and vocal fatigue (33.33%).
PB.11
Swallowing disorders in parkinson’s disease: as frequent and severe as you
think?
Kalf, Hanneke; Bloem, Bastiaan
Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
Introduction. Swallowing disorders in Parkinson’s disease (PD) or atypicalparkinsonism
(AP), are considered to be an average or highly frequent problem, depending whether
subjective or objective measures are used. Less is known about the frequency and
severity of specific swallowing complaints by these patients.
Method. Data from 168 (64% men) consecutive home-living patients visiting the
Parkinson Centre Nijmegen were collected and analyzed, including scores on the ROMP
subscale for swallowing (a validated PD-questionnaire of seven 5-score items, range 735), swallowing speed test and swallowing volume test.
Results. In total 126 patients had PD (75%) and 42 AP (25%), the latter having shorter
disease duration (5.5 vs. 7.8; p = 0.01) and higher UPDRS scores (35.6 vs. 27.3; p =
0.00). All others characteristics were statistically equal with a mean age of 64 year (SD
9.8), Hoehn & Yahr staging of 68% in stage 1-2.5, 25% in stage 3 and 6% in stage 4-5,
the mean score on ROMP-swallowing was 11 points (SD 4.3), the mean swallowing
speed 13.8 ml/s (SD 7.0) and the mean maximum swallowing volume 45 ml (SD 18.8).
The ROMP-items dichotomized (1 = no problem) showed that 50% had some limitation
in eating (time) or were cautious when dining with others (51%), 45% confirmed any
difficulty with drinking or choking (36%), 37% was concerned about swallowing
problems or even bothered by them (35%) and only 24% had difficulty with swallowing
pills. However, the most severe scores (4-5) ranged from 0% to 6%.
Discussion. Although most outcomes are patient-rated, half or less of home-living
patients with PD or AP confirm any swallowing difficulties, but severe dysphagia seems
to be infrequent.
PB.12
Effect of age, gender, height and body mass index on liquid sucking
Nascimento, Weslania; Kubo, Letícia; Dantas, Roberto
University of São Paulo, São Paulo, Brazil
Introduction: The muscles of the lips and mouth are important for sucking function. The
objective of this investigation was to evaluate the effect of ageing, gender, height and
body mass index (BMI) on the sucking of liquid. Methods: The method of evaluation
consisted of duplicate timing of the duration of continuous sucking of 40 mL of water at
room temperature using a straw with a diameter of 6 mm and another with a diameter
of 3 mm. The study included a young group (20-30 years, 45 men and 45 women) and
an elderly group (65-89 years, 45 men and 45 women). Each asymptomatic normal
volunteer was evaluated while sitting with his head at an angle of 90° between the jaw
and neck. To evaluate reproducibility, the test was performed on four different days in a
group of 15 individuals. Results: We observed a significant difference in sucking time
between young and elderly subjects, which was longer for the elderly. With the smaller
straw diameter elderly women had a longer sucking time than elderly men. In young
women, higher BMI was associated with longer duration of sucking. In elderly women
there was a negative correlation between height and sucking duration. Repetition of the
test on four different days showed the same results. Discussion: The ageing process
compromises the sucking function. This impairment is more evident in women than in
men. Height and BMI only influenced the duration of sucking in women.
PB.14
Medication swallowing difficulties reported by adults with idiopathic
parkinson's disease and oropharyngeal dysphagia
Sakellariou, Victoria1; Walshe, Margaret2
1
Trinity College Dublin, Dublin, Ireland; 2Trinity College, Dublin, Ireland
Medication swallowing difficulties reported by adults with Idiopathic Parkinson’s disease
and Oropharyngeal Dysphagia Abstract Introduction: Oropharyngeal dysphagia occurs
in almost all people with idiopathic Parkinson’s disease (IPD). This affects the intake of
food, liquids and medicines. People with IPD rely heavily on medication for relief of their
symptoms. For those with dysphagia, swallowing medications in the form of pills,
tablets, or capsules can be a real challenge in their everyday lives. The aim of this study
was to explore the difficulties, if any, that people with IPD and oropharyngeal dysphagia
report when taking medication orally and to examine the strategies used to cope with
these difficulties. Material and Methods: This study used a descriptive survey design.
Ten people with oropharyngeal dysphagia and IPD participated in the study. Medical
and swallowing history of the participants was obtained. The Mann Assessment of
Swallowing Ability (MASA) was used in combination with a questionnaire exploring
difficulty with swallowing medication. Results: The majority of participants reported
some difficulty with swallowing medication at various times. Half described having
difficulty swallowing their medicines on a daily basis. Thirty percent alter the form of
their medicines as a coping strategy but do so without informing their medical
practitioner. Discussion: Despite the small number of participants, the study
demonstrates the need for alternative forms of medication and individualized approach
to managing medication by the multidisciplinary team. The need for further research in
the area is discussed.
PB.15
Detection of signs of dysfagia in patiens in home care
Lopez Garcia, Carme1; Arroyo Aljaro, Ramon1; Bistuer Lacarra, Anna1; Moller Parera,
Mercedes1; Valles, Esther2
1
Institut Català de la Salut - CAP Drassanes, Barcelona, Spain; 2Institut Català de la
Salut - Hospital Vall d'Hebron, Barcelona, Spain
Introduction: Oropharyngeal dysphagia is a symptom that significantly affects the
quality of life and health of people. Despite its importance, represents a small number
of visits in a speech unit of a primary care health center. The purpose of this study is to
improve the detection and the derivation of this pathology in our health area. Objective
• detect signs of oropharyngeal dysphagia in the elderly population homecare • provide
strategies to prevent pulmonary complications, dehydration and malnutrition. • increase
awareness and detection of this condition by the nursing staff
Materials and methods:137 homecare patients with over 70 years and sufficient
cognitive integrity. Results: • 47 of 137 respondents (34%) showed dysphagia in the
initial questionnaire. later, after the exploration, we detected possible dysphagia in 22%
of total respondents. • from 17% of the patients that were positive in the initial
questionnaire did not follow the study.
Discussion: • the questionnaire is quick and effective to detect dysphagia in home care
patients. • the nursing staff is the key health professional for detection of dysphagia in
primary care • the withdrawal of the 17% of the patients had a marked influence on the
final results • in order to make an diagnosis is needed: clinical tests such as the MECVV, and increase endoscopic or videofluoroscopic evaluation of swallowing
PB.16
Prevalence and impact of sarcopenia in a medium to long stay unit
Rubio, Cecilia1; Duarte, E.1; Beseler, R.1; Gil, R.2; Aljibe, A.2; Moral, P.3; Moreno, I.3;
Merino, F.4
1
Department of Rehabilitation, University and Politechnic Hospital La Fe, Valencia,
Spain; 2Department of Internal Medicine, University and Politechnic Hospital La Fe,
Valencia, Spain; 3Medium to Long Stay Unit, University and Politechnic Hospital La Fe,
Valencia, Spain; 4Department of Endocrinology and Nutrition, University and Politechnic
Hospital La Fe, Valencia, Spain
INTRODUCTION Sarcopenia is a syndrome characterised by progressive and generalised
loss of skeletal muscle mass and strength with a risk of adverse outcomes such as
physical disability, poor quality of life and death. Our goal was to assess the prevalence
of sarcopenia in the Medium to Long Stay Unit of a universitary hospital and its impact
in terms of disability, dysphagia and malnutrition. MATERIALS AND METHODS
Descriptive, cross-sectional and observational study including 81 patients admitted to a
Medium to Long Stay Unit over 3 months and evaluated by an interdisciplinary team.
Administrative and management data, comorbidity (Charlson), functional capacity
(Barthel), malnutrition (MNA validated test), presence of dysphagia (test volume
viscosity), presence of sarcopenia (bioelectrical impedance analysis, manual pressure
force test with a digital dynamometer and a battery of physical performance) were
recorded. RESULTS The average age of our patients was 78.51 (SD 12). The average
stay was 18.54 days (SD 11.99). The overall prevalence of sarcopenia was 81.6%,
most of it was severe sarcopenia (91,9%). The percentage of sarcopenia among men
and women was 73.8% and 76.3%, respectively. We obtained a statistically significant
relationship between sarcopenia and age (p = 0.037), triceps skinfold (p = 0.009),
malnutrition (p = 0.025) and the estimated weight (p = 0,000). DISCUSSION The
prevalence of sarcopenia in our population was very high. Advanced age, dysphagia and
malnutrition were associated with statistically significant sarcopenia. However, this
difference was not obtained for other relevant factors: physical activity, comorbidity and
disability.
PB.18
Effect of human saliva on the consistency of thickened foods for patients with
dysphagia
Sliwinski, Edward1; Vallons, Katleen2; Oudhuis, Lizette2
1
Danone Research, Center for Specialised Nutrition, Wageningen, Netherlands; 2TNO
Food and Nutrition, Zeist, Netherlands
Rationale: Starch-based thickeners (ST), commonly used to increase the viscosity of
foods/drinks, are highly sensitive to á-amylase in saliva. This may lead to a thin and
potentially unsafe fluid consistency during consumption. The effect of saliva on the
consistency of 2 thickening powders with amylase-resistant (AR) features was studied.
Methods: AR products: Nutilis Powder (ARP) and Nutilis Clear (ARC) from Nutricia N.V.
Control: standard ST. Water and milk were thickened to custard consistency. In vitro
test: One ml of human saliva was added to 100g product. After 10 and 50 min the
amount of decantable liquid was determined. Consistency change was determined by
measuring the uniaxial compression force with a SMS TA-XT2i Texture Analyser. Human
testing: Healthy adults took one spoonful of test product and moved the tongue at ~1
rotation/s. After 10 and 20s the bolus was spat into an acid solution to stop á-amylase
activity. Viscosity was then measured in a rotational rheometer using a Couette-DIN
geometry at 50 s-1. Results: The amount of decantable liquid was significantly (p<0.05)
lower for AR products than for the control. Furthermore, the compression force for AR
products was significantly (p<0.05) higher than for the control. Milk thickened with
starch was more sensitive to amylase than water. The human testing showed the
relative viscosity of AR products to be significantly (p<0.05) higher compared to ST
after 10 and 20 s. Even the relative viscosity of AR at 20 s was significantly higher
compared to that of ST at 10 s. Conclusion: In the presence of saliva AR-thickened
drinks retain their consistency significantly better than ST-thickened drinks. Therefore,
we hypothesize that the use of AR products supports safer swallowing for patients with
dysphagia.
PB.19
The glycemic index of two gum-containing thickening powders used in the
management of dysphagia
Sliwinski, Edward
Danone Research, Centre for Specialised Nutrition, Wageningen, Netherlands
Introduction: Starch-based thickeners are commonly used to modify the consistency of
foods /drinks for patients with dysphagia. Since these thickeners have a high glycemic
index (GI), they may contribute to postprandial hyperglycemia which is a risk indicator
for patients with impaired glucose tolerance and diabetes. We assessed the GI of two
gum-containing thickeners, since the presence of fiber has been shown to reduce
hyperglycemia. Materials and Methods: Test products: Nutilis Powder (GCP) and Nutilis
Clear (GCC), both from Nutricia N.V., Zoetermeer, The Netherlands). Control: glucose.
Ten healthy subjects, after an overnight fast, consumed within 15 minutes one portion
of test product containing 25 grams digestible carbohydrates in 250 – 300 ml water.
Blood samples were collected at 15 minute time intervals. An automatic glucose
analyser (YSI, Yellow Springs Instrumentals, Yellow Springs OH, US) was used for data
collection. For both the test products and the control, the positive incremental area
under the curve (AUC) was calculated. The GI of the test products was determined by
dividing the AUC of the test product by the AUC of the control. Results: Foods with
carbohydrates that break down more slowly during digestion, releasing glucose more
gradually into the bloodstream, tend to have a low GI. Results will be presented on the
GI of two gum-containing thickening powders of which due to their amylase resistance
features a slower breakdown of starch is to be expected. Conclusions: Treatment
targeting post-prandial blood glucose levels is expected to optimise overall glycemic
control and thus to improve long-term outcomes, including reduction of cardiovascular
disease and all-cause mortality. Nutrition and diet are important tools in optimising
blood glucose levels.
PC.01
Effect of targeted hypoglossal neurostimulation on tongue strength and
endurance
Desuter, Gauthier; Francois, Sylvie; Deslangle, Valentine; Rodenstein, Daniel; Rombaux,
Philippe
Universite catholique de Louvain, Brussels, Belgium
Introduction: Neurostimulation of the hypoglossal nerve is undergoing clinical trials for
the treatment of obstructive sleep apnea. Prolonged stimulation of tongue muscles
could result in nerve lesions or muscle fatigue. We investigated the acute effects of
tongue muscles stimulation in 11 patients having completed a one year feasability trial
of targeted hypoglossal neurostimulation (THN). THN consists in a continuous cyclical
tonic type stimulation of a number of tongue muscles resulting in favorable effect on
apneas and hypopneas. Matherial & Method: We compared maximal tongue strength
(maximal pressure, Pmax) and endurance (time maintaining stable pressure at 50% of
Pmax) with stimulation turned on, then off. We used the Iowa Oral Performance
Instrument (IOPI), recording the best of three attempts. Results: Strength results are
expressed in kPa, endurance in seconds. Pmax and endurance ( On: 51 (P25:47 /
P75:52.5) kPa and 20 (P25:19 / P75:41.5) sec. ; Off: 52 (P25:49.5 / P75:56) kPa and
35 (P25:24.5 / P75:40.5) sec.) were not significantly different by Wilcoxon rank test ( p
0.119 and p 0.266). Conclusion: We conclude that after one year nightly
neurostimulation of tongue muscles there is no detectable muscle fatigue during an
acute challenge.
PC.02
The use of transcutaneous electrostimulation in the treatment of dysphagia: a
systematic review
Bogaardt, Hans1; Hakkesteegt, Marieke2; Speyer, Renée3
1
BGT Services, Leiden, Netherlands; 2Dep. of Phoniatrics, Erasmus Medical Center,
Rotterdam, Netherlands; 3Institute of Health Studies, HAN University of Applied
Sciences, Nijmegen, Netherlands
Introduction Neuromuscular electrostimulation (NMES) as a treatment modality in the
treatment of dysphagia was first described in 2001. Since its introduction the use of
NMES in the field of dysphagia treatment has been controversial. However, in the last
years a growing number of articles have been published on this subject. Aim of this
study was to review the current evidence on outcomes of electrical stimulation in
dysphagia therapy. Materials and Methods A PubMed search was conducted an initially
118 were identified. An article was considered to be relevant, when the article
presented clinical outcomes after treatment with NMES. Review articles or general
opinion articles were only included when the article consisted of a meta-analysis or
review of current articles. All studies involving healthy volunteers were excluded from
this review. Also were excluded studies on short-term outcomes of NMES. Results and
Discussion Twenty-three articles were found to be relevant for this overview. These
articles consists of eight randomized controlled trials, two case control studies, eight
cohort studies and three case reports. Furthermore, included articles included one
systematic review and one meta-analysis. The eight randomized controlled trials
included a total 325 patients. Six RCTs showed that NMES was superior to standard
therapy without NMES and two RCTs showed that the outcome was equal. None of the
RCTs showed that the outcome of NMES was inferior compared to standard therapy. A
meta-analysis was conducted on five RCTs with post-stroke patients, showing a clear
effect in favor of NMES.
PC.04
Neuromuscular electrical stimulation (nmes) in head and neck cancer patients
treated by radiation therapy with dysphagia
Woisard, Virginie; Puech, Michele; Grand, Stephane
Voice and deglutition unit ENT department, Toulouse, France
Introduction:Neuromuscular electrical stimulation (NMES) technique is a dual-channel
electrotherapy system designed specifically for the treatment of pharyngeal dysfunction.
The purpose of this study was to evaluate and compare the outcome of NMES versus
traditional swallowing therapy (TT) in head and neck patients treated by radiation
therapy. Material and methods: Twenty-one patients (18 men and 3 women) were
included. Twelve patients were randomized for NMES and 13 for TT. Inclusion criteria
were (1) patients treated by radiation therapy +/- surgery for an Head and Neck cancer
(2) a delay > 3 years after the end of treatment, (3) no récurrence of the disease, (4)
ability to swallow. Pre- and post-trial measurements were videoradiographic swallowing
evaluation, nutritional status, oral motor function test, and a self-questionnaire
(Deglutition Handicap Index, DHI). All subjects received 15 therapy sessions. Results:
Statistically significant positive therapy effects for both NMES and TT combined were
found only on the self-questionnaire (DHI). In two cases we observed a worsening on
the videofluoroscopic probably despite this result. Discussion: These results leads to
precise the indication of the NMES technique apply to swallowing disorders.
PC.05
Longstanding effect of palatal plate and oral screen training in stroke-related
dysphagia
Hägg, Mary1; Tibbling, Lita2
1
Speech & Swallowing Centre, ENT, Hudiksvall, Sweden; 2Dept. of Otorhinolaryngology,
Linköping University, Linköping, Sweden
Introduction: In addition to compensatory techniques, stroke related oropharyngeal
dysphagia can be treated with sensorimotor appliances, such as a palatal plate (PP) or
an oral screen (OS). These are aimed at triggering brain plasticity and thereby
improving swallowing capacity. It is unknown whether the different stimulation
modalities have lasting therapeutic effect. The aim of the study is to evaluate (1) the
oral sensorimotor training effect of PP and OS and the duration of this effect at longterm follow-up, (2) if the outcome differs between patients treated with PP versus OS,
and (3) if the training effect is masked by spontaneous remission. Material and Methods:
We performed retrospective and prospective studies including data from two separate
case series. In the first series, 12 patients with subjective dysphagia were trained with
a PP; in the second series 14 patients with the same diagnosis were trained with an OS.
All were evaluated by a swallowing capacity test (SCT) and a dysphagia visual analogue
scale (VAS) before and after 13 weeks of training and at late follow-up. Results and
Discussion: Both PP and OS training improved SCT and VAS significantly (p<0.001). At
late follow-up, normal SCT results were found in 27% of PP patients and 71% of OS
patients. Neither the SCT nor the VAS changed significantly from end of training to late
follow-up, which took place on average 22 months after treatment in the PP group and
13 months after treatment in the OS group. The therapeutic effect of oral sensorimotor
training in stroke patients with oropharyngeal dysphagia remains at late follow-up.
Spontaneous remission is unlikely to be the underlying etiology.
PC.06
Swallowing neurorehabilitation treatment after posterior cranial fossa
surgery.a case study.
Renzetti, Antonella1; Bartolini, Stefano1; Zanello, Marco1; Fattori, Bruno2
1
AUSL di Bologna, Bologna, Italy; 2Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
Introduction – Proprioceptive cervical receptors have important and multiple
connections to the vestibular and visual-auditory apparatus as well as to the central
nervous system. The dysfunctions of these receptors, due to posterior cranial fossa
surgery, may alter the normal afferents of sensorimotor control and therefore the
postural system of head and neck. We performed a search of the current literature to
analyze the correlations between postural alterations of the cervical tract and
swallowing disorders resulting from a damage to the mixed cranial nerves after
posterior cranial fossa surgery. We reported the results of the rehabilitation procedure
following the G.Jull and D.Falla method in 8 patients who underwent posterior fossa
meningioma surgical removal. Materials and methods – A search for scientific articles
was conducted using online databases like MEDILINE, PEDro and Pubmed. Only clinical
trials, meta analysis, randomised controlled trials and systematic reviews were
investigated. Results – A total of 16 articles were identified in the research, 10 of which
rejected because they did not meet the selection criteria. As a consequence, 6
randomised clinical trials (RCT) were analysed. Discussion – The systematic review
makes it clear that therapeutic exercise can help reduce pain, disability and the
dynamics of cervical spine. Moreover, learning motor control of the head and neck
allowed the eight people observed to recover oral feeding without aspiration for the
entire length of the meal, data which may not be found through specific and sensitive
tests limited to the time of analysis of the swallowing act.
PC.07
Effect of 8 weeks of tongue strength training on maximum isometric tongue
strength in dysphagic patients with neurodegenerative disease
Van Nuffelen, Gwen1; Vanderwegen, Jan2; Guns, Cindy1; Van den Steen, Leen1; De
Bodt, Marc1
1
Antwerp University Hospital, Edegem, Belgium; 2CHU Saint-Pierre, Brussels, Belgium
Introduction Previous research indicates that isometric tongue pressure training
improves tongue strength and swallowing in dysphagic stroke patients (Robbins et al.,
2007; Yeates et al., 2008). Data on non-stroke neurologic patients are however lacking.
The purpose of this study was to investigate the effect of an exercise scheme on tongue
strength (TS) in patients with neurodegenerative disease. Methods 10 dysphagic
patients suffering from a variety of degenerative neurological disease (Myotonic
Dystrophy, ALS, Oculopharyngeal Dystrophy, MS and MSA-P) were included. The
anterior and posterior TS was low (on average 5 kPa above the 5th percentile of their
normative value). During 8 weeks (2-7x/week) they completed an experimental therapy
protocol using the IOPI device, including both isometric strength and endurance tasks.
Outcome data were anterior and posterior TS at baseline and after completing 4 and 8
weeks of training. One-way ANOVA with post-Hoc testing was used for the statistical
analyses. Results Anterior TS improved during 8 weeks of training (Wilks’ Lambda
= .005, partial eta-sq = .741) from 26,30 kPa to 32,80 kPa after 4 weeks (p=.006) and
34,50 kPa after 8 weeks (p=.002). Posterior TS showed a similar increase after 8 weeks
of training (Wilks’ Lambda = .004, partial eta-sq = .753) from 21,70 kPa to 27,90 kPa
(4w; p=.002) to 29,40 kPa (8w; p=.002). Discussion This study indicates that the
proposed tongue strengthening protocol can significantly improve tongue strength in
neurodegenerative patients with low tongue strength. Further research is obviously
needed. The used training protocol will be presented during the presentation.
PC.08
Do changes in head and neck structures affect swallowing function after
radiotherapy in head and neck cancer?
Serel, Selen; Demýr, Numan; Karaduman, A. AyÞe
Cengýz, Mustafa; Yakut, Yavuz
Hacettepe University, Ankara, Turkey
INTRODUCTION: This study carried out to determine the effects of radiotherapy on
head and neck structures and also on swallowing function of patients with head and
neck cancer. MATERIAL AND METHODS:40 patients whose average age were
53,22±10,92 years have been evaluated before, 1 and 3 months after radiotherapy.
The posture analysis, normal joint movement of the neck, muscle strength and
endurance, the clinical and radiological swallowing function have been evaluated.
RESULTS:Head anterior tilt, kyphosis and shoulder protraction were more in the 3rd
month after RT in posture analysis(p<0,001). The neck flexion, lateral flexion and
rotation limitations have increased(p<0,001), neck muscle strength and endurance
have gradually decreased(p<0,001). At the same time, swallowing phases have been
adversely effected after radiotherapy with all these side effects(p<0,001) and the
severity of aspiration in all consistencies has increased gradually(p<0,05).
DISCUSSION:As a result, radiotherapy starts to show its negative effects from the early
period of cancer treatment. Unlike other studies, we concluded that radiotherapy affect
head and neck structures negatively and these describes how radiotherapy affect
swallowing function. So it is highly important to include head and neck structure
mobility, strength and endurance exercises in swallowing therapy.
PC.09
Effortful swallow with resistive electrical stimulation training improved
pharyngeal propulsion in post-stroke dysphagia
Park, Jin-Woo
Dongguk University Ilsan Hospital, Goyang-si, Korea, Republic of
Introduction: To evaluate that effortful swallow combined with surface electrical
stimulation used as a form of resistance training affect on pharyngeal constriction
function in post-stroke patients with dysphagia. Materials and Methods: Nineteen poststroke dysphagia patients received 20 minutes effortful swallow training with resistive
electrical stimulation during every weekdays for 4 weeks. Electrical stimulation was
applied on infrahyoid area as a resistance against hyolaryngeal elevation. Stimulation
intensity was daily adjusted till the patients could endure electrical stimulation and raise
their hyolaryngeal complex. Blinded biomechanical measurements of the extent of
hyolaryngeal excursion and the pharyngeal constriction ratio (PCR) before and after
training were performed. The change of the PCR and the relationship between
hyolaryngeal elevation and the PCR were evaluated. Results: The PCR was significantly
decreased after training (p<0.05). There was a high inverse correlation between the
hyoid elevation and the PCR (-0.62). Discussion: Effortful swallow with resistive
electrical stimulation training increased pharyngeal strength. It can be used as a
treatment to improve pharyngeal propulsion in dysphagia patients.
PC.10
The electromyography biofeedback in the treatment of oropharyngeal
dysphagia in parkinson disease: a case study
Silva, Marcela; Mituuti, Claudia; Berretin-Felix, Giedre
Bauru Dental School - University of Sao Paulo, Bauru, Brazil
Introduction: The use of electromyography biofeedback as a therapeutic strategy is
described in many health areas, showing clinical effectiveness to neuromuscular
disorders. New studies apply this technical to the treatment of oropharyngeal dysphagia,
with improvement in strong swallow and better coordination. The purpose of this study
was present the results of a therapy program using electromyography biofeedback in a
patient with Parkinson Disease and oropharyngeal dysphagia.
Material and Methods: We evaluated an elderly man (84 years) with Parkinson Disease
since 2009 and difficult to swallow, without solid foods ingestion. The patient didn’t
have benefits with conventional treatment for oropharyngeal dysphagia. Evaluation with
videofluoroscopy was made before and after 18 sessions of conventional and
electromyography biofeedback therapy. It was realized with standardized consistences
of foods (10 ml of liquid, 10 ml of pudding and a half piece of 1 cm of bread). We used
the Dysphagia Outcome Severity Scale (DOSS) (O’Neil et al., 1999) to have the
oropharyngeal dysphagia level, the penetration and aspiration scale (P-As) (Rosenbeck
et al., 1996) and the scale of food residue (Han et al., 2001).
Results: The results before and after the treatment are described in table 1.
Discussion: The use of electromyography biofeedback as an adjunctive modality of
treatment for oropharyngeal dysphagia showed efficacy in the rehabilitation of an
elderly with Parkinson Disease.
PC.11
Swallowing therapy in neurogenic swallowing disorders
Demýr, Numan; Karaduman, A. AyÞe; Serel, Selen;
Hacettepe University, Ankara, Turkey
INTRODUCTION: The study aims to determine the effectiveness of swallowing therapy
in neurogenic swallowing disorders. MATERIAL AND METHODS:14(48%) patients with
cerebrovascular disease, 8(26%) with parkinson and 8(26,6%) with multiple sclerosis
whose mean age was 56,63±10,7 years were included. Assessments were done before,
after treatment and also 1st, 3rd and 6th months. Feeding history, videofluoroscopic
assessment, oxygen saturation, quality of life, psychological status, functional
independence level, patient satisfaction assessment were performed. Patients
underwent individual therapy program 5 times per week, totally 20 sessions. After
treatment patients were followed up by home program. RESULTS: Before treatment, 9
patients(36,6%) had oral intake, while 13(43.3%) had nazogastric tubes and 8(26.7%)
had gastrostomy. There was significant change in feeding way after treatment (p<0.05).
All patients began to oral intake 3 months after treatment. Significant difference was
determined in videofluoroscopic assessment results between pre and posttreatment(p<0.05). In addition, difference in aspiration severity and presence of silent
aspiration were found significant after treatment(p<0.05). Quality of life, depression
status, patient satisfaction and functional independence level improved( p<0.05). There
were strong correlation between aspiration severity, aspiration-penetration score and
arterial oxygen amount, swallowing function(p<0.01).DISCUSSION: Therapy programs
in neurogenical disorders accelerate transition to oral intake and increase quality of life.
PC.12
Procedon as a tool for follow-up and conduct in neurogenic dysphagia – case
report
Mancopes, Renata; Constantino Drozdz, Daniela Rejane; Dorneles Bilheri, Diego
Fernando; Costa, Cintia Conceição; Mello, Fernanda
Universidade Federal de Santa Maria, Santa Maria, Brazil
Introduction: Studies relate CVA as a common cause of swallowing disorder. The
presence of dysphagia may be found in all forms of CVA, with an incidence of
bronchopneumonia three times higher than in other hospitalized patients. Objective: To
analyze the therapeutic evolution in a case of dysphagia using PROCEDON. Material and
methods: male patient, 51 years old, diagnosed with ischemic CVA, using a nasogastric
tube. To verify the therapeutic efficacy, it was applied the FOIS and videofluoroscopic
evaluation of swallowing before and after therapy. In the first clinical and objective
evaluation of swallowing, there was mild dysphagia, Rosenbeck scale of degree 2 and
FOIS 1. Results: 10 daily sessions of phonoaudiological therapy were performed while
the patient was hospitalized and after his hospital discharge, the exercises were
performed daily with the help of the caregiver who was oriented by the
phonoaudiologist. The patient was discharged without the nasogastric tube, but with
consistency restrictions, FOIS 4. After six days of discharge, a total of 15 therapy
sessions, as determined by PROCEDON, the patient remade the objective examination
and clinical evaluation of swallowing, presenting functional swallowing in the Rosenbeck
scale degree 1 and FOIS 7. Conclusion: It was observed that after the
phonoaudiological treatment the patient presented effective improvement in swallowing,
progressing from a frame where he was only fed via tubing, to a full and unrestricted
feeding via oral ingestion, and the PROCEDON being a viable protocol for follow-up and
conduct in the therapeutic evolution of this case.
PC.13
Longstanding effect of oral sensorimotor training in stroke-related dysphagia
Hägg, Mary1; Tibbling, Lita2
1
Speech & Swallowing Centre, Hudiksvall, Sweden; 2Dept. of Otorhinolaryngology,
Linköping University, Linköping, Sweden
Introduction: In addition to compensatory techniques, stroke related oropharyngeal
dysphagia can be treated with sensorimotor appliances, such as a palatal plate (PP) or
an oral screen (OS). These are aimed at triggering brain plasticity and thereby
improving swallowing capacity. It is unknown whether the different stimulation
modalities have lasting therapeutic effect. The aim of the study is to evaluate (1) the
oral sensorimotor training effect of PP and OS and the duration of this effect at longterm follow-up, (2) if the outcome differs between patients treated with PP versus OS,
and (3) if the training effect is masked by spontaneous remission. Material and Methods:
We performed retrospective and prospective studies including data from two separate
case series. In the first series, 12 patients with subjective dysphagia were trained with
a PP; in the second series 14 patients with the same diagnosis were trained with an OS.
All were evaluated by a swallowing capacity test (SCT) and a dysphagia visual analogue
scale (VAS) before and after 13 weeks of training and at late follow-up. Results and
Discussion: Both PP and OS training improved SCT and VAS significantly (p<0.001). At
late follow-up, normal SCT results were found in 27% of PP patients and 71% of OS
patients. Neither the SCT nor the VAS changed significantly from end of training to late
follow-up, which took place on average 22 months after treatment in the PP group and
13 months after treatment in the OS group. The therapeutic effect of oral sensorimotor
training in stroke patients with oropharyngeal dysphagia remains at late follow-up.
Spontaneous remission is unlikely to be the underlying etiology.
PC.14
Therapies & techniques used by irish speech & language therapist working
with clients with dysphagia
McCurtin, Arlene; McCurtin, Arlene
University of Limerick, Limerick, Ireland
Introduction: Dysphagia is a core area of practice for speech & language therapists
although it is not wholly clear what therapies and techniques are used by clinicians. This
study aimed to scope practice in the area. Materials & methods: A survey methodology
was employed explicating therapies used and reasons for use. An electronic
questionnaire was distributed via a number of database gatekeepers and a link was
posted on the national professional website. Descriptive and inferential statistics were
used to analyse the data. Results: 116 responses were received. SLTs use a limited
repertoire of dysphagia interventions, practice being essentially represented by three
high use therapies with over three-quarters of respondents selecting these options.
Neuromuscular and technology-based therapies are poorly represented in favoured
choices. The total intervention pool effectively constitutes nineteen therapies and
techniques. Bolus modification and swallow clusters are evident on multidimensional
scaling. Few changes occur to preferred options over the clinical lifespan. Categories of
therapies may reflect populations served e.g. swallow techniques are most used by
adult clinicians. Respondents have clear justifications for using and not using therapies
mostly related to client suitability, clinical experience and knowledge based reasons.
Discussion: SLTs use a limited range of dysphagia therapies suggesting a professional
culture focused on specific intervention options and being predominately compensatory
in nature. Furthermore decision-making influences are also limited and the influence of
research evidence is weak. There are implications for evidence based practice.
PC.15
An investigation into the effects of neuro-muscular electrical stimulation
(nmes) on swallowing function in patients presenting with persistent
dysphagia.
Pownall, Susan1; Enderby, Pamela2
1
Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United
Kingdom; 2University of Sheffield, Sheffield, United Kingdom
Introduction NMES is not currently utilized in the UK for patients with dysphagia. A
recent systematic review found conflicting evidence for using NMES to treat dysphagia.
A particular approach to NMES-Ampcare Effective Swallowing Programme (ESP) places
electrodes sub-mentally only, as evidence suggests when stimulating neck and submental muscles simultaneously, muscles that depress the larynx, over-ride muscles,
which promote elevation. Method Feasibility study investigating NMES of laryngeal
elevation musculature on swallowing using ESP. Case series design including 5 patients
with persistent dysphagia (3-24 months since onset) who showed decreased laryngeal
elevation on Videofluoroscopy(VF). Participants received 4 weeks of intervention (5
days p/week for 30 minutes).Swallowing was re-assessed by VF post intervention. Data
was collected using 3 validated dysphagia scales Results 5 patients were recruited. Two
with diagnosis stroke, two head/neck cancers and one skull base osteomyelitis. All
participants completed 20 sessions, demonstrating acceptability of the intervention.
Five showed improved swallowing function. Two patients (diagnosed stroke) returned to
full oral diet and ceased PEG feeding. Three patients introduced increased
amounts/ranges of food to their oral intake, although continued to receive nutrition via
PEG. One of these participants returned to full oral intake after completing the trial
suggesting carryover Discussion Results suggest this technique may be effective for
some patients presenting with dysphagia. If results were replicated in a randomised
trial it would suggest the need for service re-design and policy change in the UK.
Benefits would be likely through improved QOL and healthcare savings from reduced
costs/complications of tube feeding.
PC.16
The feasibility of neuromuscular electrical stimulation for the treatment of
oropharyngeal dysphagia at 1 week post stroke- a pilot study
McLaughlin, Carolee; Fullerton, Ken; Wiggam, Ivan
Belfast Trust, Belfast, United Kingdom
Introduction Dysphagia (swallowing difficulties) occurs in 25-53% of patients post
stroke (Smithard 2001). Treatment of dysphagia is crucial as it may reduce medical
complications such as pneumonia, dehydration, malnutrition aspiration and death (Perry
2001). A new and controversial approach for the treatment of dysphagia is
neuromuscular electrical stimulation (NMES). NMES aims to accelerate muscle
strengthening and cortical organisation however, it is unknown whether or not acute
dysphagic stroke patients can actually tolerate NMES. This is the reason for this
tolerability study. Methods 20 acute dysphagic stroke patients were offered 60 minute
sessions of NMES for 5 working days. All subjects had a clinical and objective
assessment of their swallow. The length of sessions and acceptability of each treatment
were recorded. Additional outcome measures included functional oral intake, clinical
improvement in swallowing and subjects perceptions of their swallowing measure pre
and post treatment. Results 20 patients with stroke (14 TACS, 5 LACS and 1 PACS),
mean age 77.6 years and median Barthel score of 3 were recruited. Overall, 66.2% of
treatment session times were tolerated. Overall 70% rated NMES as ‘good’. Significant
change was evident in swallowing ability with 17/19 upgrading diets of which 4/6
progressed from tube feeding to oral intake. Conclusions Acute dysphagic stroke
patients rated NMES as an acceptable treatment and tolerated 2/3 of the protocol. An
improvement in swallow function was observed. These results will inform a RCT trial on
the efficacy of NMES for the treatment of dysphagia in acute stroke patients.
PC.17
Survey on oral functional training and required care among communitydwelling frail elderly individuals in japan
Momose, Yumiko; Fujino, Ayumi; Amaki, Nobuko; Kamakura, Yayoi
Aichi Prefectural Univirsity, Nagoya, Japan
Introduction.Although it is estimated that the number of elderly individuals at risk for
dysphagia is increasing, the provision of oral functional training is low, and factors
relating to this disparity need to be understood. The purpose of this study was to clarify
care needs and the actual conditions of oral functional training among communitydwelling frail elderly individuals.
Methods.Subjects included 1,044 staff members selected at random from 3,500 elderly
day-service centers. Self-report questionnaires were sent by mail to the directors of the
day-service centers. After being completed anonymously, questionnaires were placed in
an enclosed return envelope that was sealed and returned by post. The questionnaire
included items related to the characteristics of the subjects and the extent of oral
functional training for day-service users.
Results The questionnaire was returned by 272 respondents (response rate 26.1%).
The majority of respondents were female (204; 75.0%) who had worked at their
current workplace for an average of 5.9 years. The mean age of the respondents was
45.9 years (SD=10.2), and 106 subjects (39.0%) were nurses. The average number of
users per day of a day-service center was 28.2 (SD=11.3). The average number of
users with care needs was 23.4 (SD=28.7), and the average number of users benefiting
from additional oral care training was 5.7.
Discussion.These findings indicate that it is important to develop effective educational
programs related to oral functional training for elderly individuals so that health care
staffs can improve oral functional training skills.
PC.18
Swallowing rehabilitation in a young patient with total glossectomy due to
neoplasm in fanconi's anemia: a case report
Clemente, Ivet1; Aviñó, Conxa2; Tobed, Marc3
1
Hospital de Palamós (Girona), Palamós, Spain; 2Hospital de Palamós, Palamós,
Spain; 3Hospital J.Trueta, Girona, Spain
Head and neck squamous cell carcinoma are among the most common tumors to
develop in patients with Fanconi anemia (FA). We report the case of a 32 years old
male with tongue's base squamous cell carcinoma associated to FA with early lymph
node metastases and early soft tissue invasion.The patient was submitted to surgical
resection, which required a total glossectomy and floor's mouth removal, with a parcial
supraglottic laringectomy.Quadriceps autologue graft on tongue was immediately
performed, being also necessary a parenteral endoscopy gastrostomy (PEG) and a
tracheostomy. Fiberoptic endoscopy evaluation of swallowing (FEES) at the early
postoperative stage revealed good airway closure at vocal folds and sinus piryform in
absence of epiglottis. These measures lead therapy to be established in two phases.In a
primary stage, the patient is to achieve a better sensitivity and mobility of all oral
remaining structures and to perform Mendelsohn maneuver (voluntary prolongation of
laryngeal elevation and cricopharyngeal opening during swallow). In a secondary stage,
the main objective is to provide the patient with compensatory mechanisms to manage
dysphagia despite the surgery effects, and to increase swallowing competence avoiding
aspiration.Progress will be monitored by sequential follow-up modified barium swallow
(MBS) examinations. As we show in this case, preliminary findings on oropharyngeal
functional exploration and instrumental evaluation may be fundamental for guiding the
dysphagia rehabilitation.In this sense, these measures allow the establishment of early
speech language pathology's intervention,which may improve functional deglutition
prognosis.MBS follow-ups and the evidence-based practice will establish, through the
outcomes, the efficacy of the treatment.
PC.19
Encouraging cortical plasticity in dysphagic patients
Barritt, Andrew1; Smithard, David2
1
St George's Hospital, London, United Kingdom; 2East Kent Hospitals NHS Trust,
Ashford, United Kingdom
Swallowing dysfunction can occur acutely in a large proportion of stroke patients but it
is only transient in the majority of cases. However, persistent dysphagia can signify
considerable morbidity and a risk of dehydration, malnutrition, aspiration pneumonia
and death. Specific areas of the cerebral cortex are responsible for the effective co-
ordination of swallowing and are normally represented bilaterally. Following ischaemic
damage, studies have shown that the contralateral hemisphere can undergo
reorganisation with plasticity of the remaining cerebral cortex, a process which is
thought to be dependent on continued rehabilitation. There are structural and electrical
forms of inhibition throughout the central nervous system which can prevent this plastic
change, particularly after injury, and may explain why some stroke patients do not
regain safe swallowing. A selection of experimental techniques, inlcuding pharyngeal
and faucial pillar stimulation, and direct electromagnetic stimulation of the cortex itself,
have provided some hope for encouraging cortical rewiring and return of swallowing
function. In addition, ongoing advances in plasticity research over the last two decades
has yielded numerous factors within the nervous system which could be manipulated to
enable plasticity in an otherwise inhibitory environment, including components of
oligodendrocyte myelin and extracellular matrix proteoglycan molecules, GABAergic,
cholinergic, dopaminergic and noradrenergic neurotransmission and neurotrophic factor
signaling. Here we discuss the exciting prospect for these therapeutic avenues to be
explored specifically for the treatment of dysphagia which, in conjunction with existing
rehabilitative strategies, could help restore safe swallowing function to patients.
PD.01
Killian-jamieson bilateral diverticulum demonstrated by videofluoroscopic
swallowing study: case report
Scheeren, Betina; Maciel, Antonio Carlos; Kist de Mello, Renato José; Gonçalves, Caren
Meneghetti
Santa Casa de Porto Alegre Hospital, Porto Alegre, Brazil
Introduction: The Killian-Jamieson diverticulum was described in 1983 by Ekberg and
Nylander and is located in the anterolateral wall of the cervical esophagus below the
cricopharyngeal muscle. The symptoms includes dysphagia for solids and food
impaction. Case Report: A 56-year-old male sent to perform videofluoroscopic
swallowing study complaining of dysphagia for solids and food impaction. There was no
abnormal findings on upper gastrointestinal endoscopy and the contrast radiography of
the esophagus described a Zenker diverticulum. The videofluoroscopic swallowing study
which included dynamic images of oral, pharyngeal and esophageal phases of
swallowing, in frontal and lateral projections, performed by a radiologist and a speechlanguage pathologist, demonstrated the presence of two diverticula below the upper
esophageal sphincter. Discussion: The Killian-Jamieson diverticulum occurs due to
herniation of mucosa and submucosa of the hypopharynx in an area of weakness of the
wall under the cricopharyngeal muscle. In this case, it was necessary to perform
videofluoroscopic swallowing study in order to have a differential diagnosis of Zenker
diverticulum. Thus, this exam is an important tool in disorders of the hypopharynx and
esophagus,because the complaint of cervical dysphagia may have a esophageal cause.
Conclusion: The videofluoroscopic swallowing study was an important exam to identify
and diagnose the Killian-Jamieson diverticulum, an esophageal cause of dysphagia.
PD.02
The usefulness of transnasal esophagoscopy in the evaluation of patients with
deglutition
disorders
Farneti, Daniele1; Genovese, Elisabetta2; Chiarello, Giulia3; Pastore, Antonio3
1
Audiology and Phoniatry Department, Rimini, Italy; 2Audiology Department, University
of Modena, Modena, Italy; 3ENT Division, University of Ferrara, Ferrara, Italy
INTRODUCTION The transnasal esophagoscopy (TNE) is a procedure used for decades
in the instrumental evaluation of patients with ENT complaints. Its use is still limited in
patients with deglutition disorders. The paper considers the practical implications in the
use of TNE technique in a phoniatric setting. MATHERIAL AND METHODS TNE is used as
an out-patients procedure. The patient is sitting upright in an examination chair, facing
the clinician. A 70 cm flexible endoscope, 5.2 cm diameter, is used. No premedication
or topical nasal anesthesia is performed. 20 patients (13M/7F, range 19-78 yrs, mean
age 50,51 yrs), among 437 consecutive outpatients seen in our Department from
August to December 2011, underwent TNE (retrospective analysis). Patients were
selected based on a reflux finding index (RFI) >13, Reflux finding score (RFS) > 7 and
FEES alterations (false routes, pre and post-swallow alterations). Smokers, alcoholics,
patients with neurological, gastroenterological pathologies or acute/chronic
rhinosinusitis were excluded. RESULTS Mean RFI is 16.3 and mean RFS is 9.8. At FEES
no aspiration was documented but only 5 episodes of penetration. Pre-swallow
alterations (spillage, delay in swallowing reflex) were documented in 7 patients and
post-swallow alterations in 9 patients (pooling). The main TNE findings were: 10
esophagitis (3 minimum alterations), 1 gastroesophageal junction incontinence, 2 hiatal
hernia, 4 motility alterations, 2 diverticula, 1 carcinoma. DISCUSSION Esophageal
alterations are not rare in patients with deglutition disorders. TNE is a safe, reliable and
cost-effective technique useful in the evaluation of the esophageal phase of swallowing.
PD.03
Is it possible to predict the success of myotomy in non-zenker related
cricopharyngeal dysphagia?
Feussner, Hubertus
Klinikum rechts der Isar der TUM, Munich, Germany
Introduction: Cricopharyngeal myotomy (CM) is the treatment of choice in isolated
cricopharyngeal dysphagia (CD). However, CM is not always successful with a failure
rate of 20-30 % of cases according to the literature. This study assesses the influence
of the underlying disease upon the outcome. Material and Methods: Follow-up was
performed in 26 patients of a group of 36 patients with isolated CD who had been
treated with CM. The outcome was evaluated according to the cause of CD (neurological,
myogenous, idiopathic). Results: In the group of 36 patients, OR time was 42 minutes
(range 28-105). Hospital stay was 11 days (range 3-42). 3 cases were complicative
with 1 fatal event due to aspiration. In 26 cases, a follow-up could be achieved after 26
months (range 4-49) with functional assessment in 21 cases. In n=14 patients,
dysphagia was completely eliminated, in n=7 it was improved. The situation was not
improved in n=4 patients and in 1 patient the symptoms had worsened. N=18 patients
had had a PEG which could be removed in 14 patients. Patients with complete relief and
those with an improvement of their symptoms were assigned to group I, the remainder
to group II. Table 1: Underlying disease Group I (free of symptoms/improved) Group II
(unaltered, worsened) Idiopathic 10 (83 %) 2 (17 %) Neurogeneous 8 (80 %) 2 (20 %)
Myogeneous 3 (75 %) 1 (25 %) As shown in table 1, no significant differences in the
success rates could be found among the 3 groups. Discussion: The underlying pathology
alone is not a reliable predictor of the outcome of CM.
PD.05
Is the cough test useful for diagnosing silent aspiration after stroke onset?
Guillén-Solà, Anna; Chiarella, Sandra; Alvarado, Martha ligia; Boza, Roser; Duarte,
Esther; Marco, Ester
Hospitals Mar-Esperança. Parc de Salut Mar, Barcelona, Spain;
Introduction: To evaluate the usefulness of the cough test (CT) with citric acid aerosol
in the diagnosis of the patient with Stroke Silent Aspiration. Material and Method: Ct
was performed in 134 consecutive stroke patients admitted to a Rehabilitation
Department. The criteria for inclusion in the study were: 1) acute stroke patients within
3 weeks of evolution, 2) videofluoroscopy (VFSS) assessement according to the
Penetration Aspiration Scale 3) Test of the citric acid cough. Function scales were
analyzed and demographic variables and the correlation between CT and VFSS.
RESULTS: Final sample of 84 patients with a mean age of 67 years. 32.1% of patients
had aspiration. The cough test showed 22.6% of silent aspirations in isolation. When
performing videofluoroscopy got confirmation for a cough test sensitivity 18.8,
specificity 76.5%, PPV 15.8%, NPV 80% and an efficiency test of 0.7. CONCLUSIONS:
CT as isolated screening test is not useful for detecting silent aspiration in subacute
stroke patients.
PD.06
Rate of diagnosis and treatment recommendations for oropharyngeal
dysphagia at discharge reports of patients with acute stroke in a tertiary
hospital
Carrión Pérez, Franscisca; Pozuelo Calvo, Rocío; García Montes, Inmaculada; Pérez
Ureña, Mª Belén; Rodriguez Moreno, Sofía
Servicio de Medicina Física y Rehabilitación. Hospital Universitario Virgen de las Nieves,
Granada, Spain
Introduction: Oropharyngeal dysphagia is a high prevalent pathology among
hospitalized patients, especially in those who have suffered an acute stroke (37% 78%). However, neither the diagnosis of dysphagia nor it´s treatment
recommendations are often listed in the discharge report. The aim of this paper is to
assess the rate of hospital discharge reports that reflect this diagnosis and treatment
recommendations in patients with acute stroke. MATERIALS AND METHODS Design:
Retrospective descriptive study Sample Discharge reports of patients with acute stroke,
in which dysphagia diagnosis was included (CIE.9 Codes: 787.20-787.29) as primary or
secondary diagnosis during the first half of 2011 in a tertiary care hospital Hospital
Variables Indications for dysphagia treatment, assessment by the Department of
Dietetics and Nutrition Unit or Phoniatrics Rehabilitation, and enteral feeding at
discharge RESULTS: The total amount of patients included in our study who had
suffered an acute stroke was 546, of which only 21 were classified with the diagnosis of
dysphagia (3.84%). From those 21 patients, 33.3% included dietary recommendations
in the report released. No patients received other treatment recommendations. There
where evaluated by the speech pathologist 38% of patients, and 21% of them by the
Nutritionist. Only 9.5% of them were receiving enteral feeding at discharge
DISCUSSION: Rates of both diagnosis and treatment recommendations for
oropharyngeal dysphagia at discharge reports of patients who have suffered an acute
stroke at our hospital are much lower than those reported in scientific literature. This
may have serious implications for patient safety and continuity of care for other health
levels. Further measures are needed to improve this aspect of health care.
PD.07
Acoustic and ultrasonic study of pharyngeal swallowing in healthy subjects
based on the volume and the consistency of the bolus.
Hammoudi, Karim1; Marmouset, Franck1; Boiron, Michèle2; Patat, Frédéric3; Beutter,
Patrice1; Morinière, Sylvain1
1
CHRU Tours, Tours, France; 2Tours University, Tours, France; 3Inserm 930, Tours,
France
Introduction: the noise of high swallowing consists of three main components of sound
generated by the passage of the bolus and the movement of throat structures. The aim
of our study was to correlate these sound components to the corresponding ultrasound
events (initial displacement of the upper esophageal sphincter (UES), passage of the
bolus through the UES and the UES back to its original position). In a second step we
studied the changes of sound components and ultrasonic collected data by the volume
and consistency of the bolus. Material and Methods: twenty three healthy subjects were
included. The acoustic and ultrasonic recordings were performed using a microphone
and an ultrasound machine connected to the same computer equipped with the
software "visualisation" for the synchronized acquisition of the two signals. Subjects
performed three swallows of 3, 5 and 10 ml of water, yogurt and puree. Five acoustic
parameters, seven ultrasonic parameters, the correlation between the sound
components (SC1, SC2 and SC3) and the corresponding sonographic events were
studied. Statistical comparisons were performed using the Student t test (significance if
p <0.05). Results: the volume and the consistency of the bolus affects some acoustic
and ultrasonic parameters. The correlation between the sound components and the
corresponding ultrasound events were 100%, 13% and 7%. Discussion: CS2 is the
most important sound component within the noise of swallowing. The ultrasonic
technique is a promising method for studying the UES and must be improved. The
acoustic and ultrasonic synchronized acquisition can correlate CS1 to the initial
displacement of the UES.
PD.08
Pilot study: relationship with the nihss dysphagia in patients with acute
ischemic stroke
Soria, Franciele1; Furkim, Ana Maria2; Nunes, Maria Cristina3; Pinto, Gisele3; Lange,
Marcos3; Zetola, Viviane3
1
Faculdade Assis Gurgacz, Toledo, Brazil; 2UFSC, Florianopolis, Brazil; 3UFPR, Curitiba,
Brazil
INTRODUCTION: In the initial clinical evaluation and sequential patient with stroke is
mandatory to use method of monitoring the level of consciousness and neurological
deficit. It is recommended for this purpose the application of the Glasgow coma scale
(TEASDALE & JENNETT, 1974) and range of strokes from the National Institutes of
Health Stroke (NIHSS), (LYDEN et al. 2001). The objective of this study is correlate the
initial value of the NIHSS to dysphagia in patients with acute ischemic stroke.
MATERIALS AND METHODS: Prospective pilot study conducted at Hospital de Clinicas of
the Paraná, with 17 patients diagnosed with acute ischemic stroke confirmed by
computed tomography. All patients were evaluated by a neurologist and
nasolaringofibroscópica evaluation of swallowing (FEES®), (LANGMORE, SCHATZ &
OLSEN, 1988) and the consistencies food liquid, nectar, honey and pudding before 24
hours of stroke. RESULTS: Of 17 patients, 11 (64.70%) were female and six (35.30%)
males aged 50-84 years. Of the 17, ten (58.82%) had NIHSS score from 1 to 11 and
seven (41.18%) patients had scores between 12 to 22. Only three (17.54%) patients
with NIHSS of 1, 18 and 15 had oropharyngeal dysphagia. DISCUSSION: Authors report
that the use of the NIHSS scale on admission of patients with stroke to identify the risk
of dysphagia may be a screening tool for dysphagia (BRAVATA et al., 2009). Our results
suggest that a small percentage of patients have oropharyngeal dysphagia evaluated by
FEES®. In this small pilot sample was not possible to identify the correlation between
dysphagia and the NIHSS scale.
PD.10
Standard laryngotracheal penetration and aspiration in patients with stroke
Soria, Franciele1; Furkim, Ana Maria2; Czechowski, Aliana3; Pinto, Gisele3; Santos,
Rosane3; Zanata, Isabel3; Nunes, Maria Cristina3; Oliveira, Silvia3
1
FAG, Toledo, Brazil; 2UFSC, Florianopolis, Brazil; 3UTP, Curitiba, Brazil
INTRODUCTION: In nasolaringofibroscópica evaluation of swallowing (FEES®),
(LANGMORE, SCHATZ & OLSEN, 1988) can evaluate the pattern of penetration and
tracheal aspiration occurs earlier by observing whether laryngeal surface of epiglottis,
laterally by ariepiglóticos ligaments and/or further the space between. The objective of
this study was characterize the penetration and/or tracheal aspiration in patients with
stroke. MATERIALS AND METHODS: A prospective study at the Clinical Hospital of
Parana in ten patients with diagnosis of stroke and all underwent FEES®. Data were
noted laryngeal sensitivity: this normal, decreased or absent and present patterns of
penetration and/or tracheal aspiration: anterior, lateral or posterior. RESULTS: Of ten
patients, six (60%) were female and four (40%) males aged 33-79 years. In relation to
a sensitivity one (10%) patient showed this sensitivity decreased and nine (90%)
sensitivity absent. In the oral phase two (20%) had difficulty in oral ejection and two
(20%) premature loss. In the pharyngeal phase two (20%) had delayed onset of the
pharyngeal phase, two (20%) decrease in laryngeal elevation, two (20%) of vocal fold
paralysis, three (30%) pharyngeal residue in valleculae and epiglottic and five (50%)
pharyngeal residue in piriform recesses. The standard penetration and anterior tracheal
suction occurred in one (10%) patients, the pattern in a lateral with one (10%), the
latter six (60%), the former with a lateral one (10%) and the former with lateral and
posterior in one (10%) patients. DISCUSSION: There are few studies that looks at the
pattern of penetration and tracheal aspiration. There is need to increase the sample.
PD.12
Neurogenic dysphagia in comprehensive stroke unit care and structural
components for a dysphagia program
Ickenstein, Guntram W.1; Isenmann, Stefan2; Ende, Franziska1; Müller, Rainer3;
Bodechtel, Ulf3; Reichmann, Heinz3; Meisel, Andreas4
1
HELIOS General Hospital Aue - Technical University Dresden, Aue, Germany; 2HELIOS
General Hospital Wuppertal - University Witten-Herdecke, Wuppertal, Germany; 3Carl
Gustav Carus University Hospital Dresden, Dresden, Germany; 4Charite University
Hospital Berlin, Berlin, Germany
Introduction: An important aim of the Stroke Unit concept is the standardisation of
diagnostics in stroke patients in order to help the nursing staff, swallowing therapists,
dieticians and doctors for an early identification of neurogenic oropharyngeal dysphagia
(NOD). This enables the team to initiate appropriate therapeutic measures and to avoid
complications such as aspiration pneumonia and malnutrition. Methods: With regard to
the clinical assessment of swallowing by nursing staff and swallowing therapists a
standardized swallowing assessment for dsyphagic patients and a standardized clinical
swallowing examination (CSE) according to validated criteria is recommended. The
clinical assessments should be followed by specific technical examinations like the
swallowing endoscopy and/or videofluoroscopy. Results: Studies with severe dysphagic
stroke patients show that age, neuroanatomical lesions and scoring parameters (clinical
assessment and technical examination) are important to predict the outcome of patients.
With regards to the grading of dysphagic stroke patients the functional communication
measure swallowing (FCM) as well as the penetration-aspiration-scale (PAS) show in a
multivariate analysis an AUC of 73% for the endpoint “tube-feeding at the end of
neurorehabilitation (FCM 1-3 at day 90)”. In a longitudinal study for the implementation
of a dyphagia programm in a certified stroke unit a reduced rate of pneumonia and inhospital-mortality could be seen. Discussion: A standardized dysphagia concept enables
the team to avoid complications such as stroke-associated pneumonia (SAP) and lead to
a better prediction of outcome with a longterm therapeutical concept. Keywords:
neurogenic dysphagia, stroke, clinical swallowing examination, swallowing endoscopy
PD.13
Recording of speech muscles activities by surface electromyography>
Jalilian, Yasaman1; Talebian, Saeed2; Shadmehr, Azadeh3
1
Welfare Science and Rehabilitation of Tehran University, Tehran, Iran; 2Tehran
University of Science, Tehran, Iran; 3Tehran University of Medical Science, Tehran, Iran
Introduction: Muscles that contribute in production of sound have important rolls in
specific language. Knowledge of normal activities of these muscles is very important in
language dysfunction and pathologic conditions. Needle electromyography is
complementary approach in clinical evaluations of above conditions and is pain full and
very specific method, which needs serenity of patient. Surface electromyography can be
used to neurophysiological behaviors and effect of treatment interventions and is
accepted by scientific academies. The purpose of this study is appointment of new
approach in this area Method:Sixty eight healthy subjects (34 female and 34 male) in
range of 20-30 ages after supplement of questioner form contribute in this study.
Subjects sited in chair with arm rest and recording electrodes placed on muscles of
Thyroarytenoid and Cricothyroid of both side (right and left) at middle and lower parts
of throat, near of 1 cm from mid line. Silent activity and fricative voice (z-zh) and
voiceless (s-sh) activities recorded randomly at 10 second with interval rest between
them for 5 repetition. All of signals processed and then compared in time, frequency
and non linear measurements Results: Muscle activities (RMS) and values of spectrum
frequency (median) are greater in production of fricative voice in comparison to rest
conditions (P<0.05). Also there was significant different between fricative voice with
voiceless in recurency (P<0.05). Discution:Surface activity recording of Thyroarytenoid
and Cricothyroid muscles is possible and is sensitive in parameter of non linear values.
Surface electromyography is new approach for assessment of above muscle in clinical
evaluation of speech pathologic conditions.
PD.14
Oral health in stroke patients with oropharyngeal dysphagia
Ortega, Omar1; Parra, Carlos2; Zarcero, Silvia2; Nart, José2; Sebastian, Marisa3; Ciurana,
Ana M3; Serrano, Estela3; Pradas, Ana3; Clavé, Pere1
1
Unitat d’Exploracions Funcionals Digestives, Hospital de Mataró, Mataró,
Spain; 2Department of Periodontology, Universitat Internacional de Catalunya,
Barcelona, Spain;3Department of Nursing, Hospital de Mataró, Mataró, Spain
BACKGROUND: Oropharyngeal dysphagia (OD) and aspiration are potential risk factors
and independent predictors of mortality in patients with stroke. Oral health status is
correlated with oral colonization of respiratory pathogens. AIM: To asses the oral
hygiene status and the prevalence of periodontal disease and dental caries in stroke
patients with OD. PATIENTS AND METHODS: 28 consecutive patients (80.1±6.47 years,
Charlson co-morbidity index 3.86) with OD associated to stroke were enrolled in this
observational-transversal study. OD and aspiration were evaluated by the Volume
Viscosity Swallowing Test (V-VST). Oral health was assessed by: a) the oral hygiene
status by the Simplified Oral Hygiene Index (OHI-S); b) a complete periodontal charting,
assessing the periodontal pocket depth, clinical attachment loss and bleeding on
probing to study periodontal diseases (periodontitis, gingivitis), and c) the presence of
dental caries. RESULTS: Up to 65.21% stroke patients presented V-VST signs of
impaired safety and 29.16% major signs of overt aspiration, and 25% oropharyngeal
residue. 42.86% of stroke patients were edentulous. Among the dentate, stroke
patients presented: a) 6.67% good (OHI-S 0-1), 20% fair (OHI-S 1-3) and 73.33%
poor (OHI-S 3.1-6) oral health status; b) 100% periodontitis; c) 61.54% caries.
CONCLUSIONS: Stroke patients with OD presented high prevalence of clinical V-VST
signs of impaired safety of swallow and a poor oral health status with high prevalence of
periodontal diseases and caries. These patients are at great risk to develop AP. We
recommend a policy of universal oral health assessment in stroke patients with OD.
PD.15
Prescription pattern of thickening agents and hospital admissions due to
aspiration in patients with dysphagia
Garin, Noe; De Pourcq, Jan Thomas; Cardenete, Joana; Fonts, Nuria; Cardona, Daniel;
Mangues, Maria Antonia
Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
INTRODUCTION Assessment of patients with dysphagia is performed by a
multidisciplinary healthcare team. In our case, an enteral nutrition program (ENP) is
conducted by hospital pharmacists after diagnosis. Our aim was to analyze prescription
pattern of thickening agents in patients with dysphagia and to quantify hospital
admissions due to aspiration. MATERIALS AND METHODS Retrospective study in a
tertiary teaching hospital in Barcelona, including patients of the ENP from 1998 to 2012.
Description of prescription pattern included: proportion of patients with dysphagia, age
at prescription, liquid or liquid/solid dysphagia, responsible specialist, most prevalent
related diseases, type of diagnosis (videofluoroscopy vs other) and consistence in case
of videofluoroscopy. Related complications were quantified as the number of admissions
due to aspiration in these patients. RESULTS During this period, 2451 patients were
included in the ENP, among which 993 suffered from dysphagia. Additional data was
obtained from clinical courses, so that 758 patients were finally analyzed. Prescription
pattern information is summarized on Table 1. Management with commercial thickeners
was necessary in 268 patients, whilst 490 needed other special nutrition management
(gastrostomy, nasogastric tube, jejunostomy or oral supplements). Prevalence of
aspiration was higher in patients taking thickeners (12,0%), comparing to more
aggressive management (9,0%). DISCUSSION A significant proportion of patients in
the ENP had dysphagia, among which one third needed thickeners in liquids. Head and
neck cancer and stroke are the two main causes of dysphagia, whilst most prescriptions
came from Neurology or Nursing centers. Aspirations happened in 12% of patients
taking thickeners, but could be underestimated.
PD.16
A scoping review of physiological markers associated with impaired
swallowing safety: part 2. Hyoid factors
Steele, Catriona1; Cichero, Julie2
1
Toronto Rehabilitation Institute - University Health Network, Toronto,
Canada; 2University of Queensland, Brisbane, Australia
Introduction: A literature review was conducted to investigate parameters correlated
with impaired swallowing safety and aspiration. Part 2 of the review focuses on factors
related to hyoid excursion. Methods: A multi-field search was performed, using Ovid
MEDLINE; AMED; EMBASE; Health and Psychosocial Instruments; and PsychINFO
(English language, 1985 to current). Search terms included the MeSH Headings
“Swallowing” OR “Deglutition” AND a title search term “Hyoid”. Results:43 nonduplicate articles were found; 26 were retained following a title/abstract review for
relevance to swallowing safety. Information extracted included research design, sample
size, objectives, conclusions and a ‘level of evidence’ rating. Discussion: A hierarchy of
hyoid factors related to aspiration emerged: 1) Complete absence of hyoid movement;
2) reduced anterior range of hyoid movement (particularly <27% of the C2-C4
distance); 3) discoordination between movements of hyoid and larynx; 4) weak
contraction of the suprahyoid muscles; and 5) possibly, hypertonicity of the infrahyoid
and middle pharyngeal constrictor muscles, which serve as hyoid stabilizers. Anterior
hyoid movement appears particularly critical and is linked to posterior tongue-palate
pressures, geniohyoid muscle contraction, epiglottic deflection, UES opening and
penetration-aspiration. Surface EMG is a non-invasive way of measuring muscle activity
associated with hyoid movement. Dual-axis swallowing accelerometry also holds
promise as a non-invasive technology for capturing accurate measures of hyoid
movement, but these require filtering to remove artifact. Signal processing classifiers
hold promise for discriminating aspiration in accelerometry data. Disclosure: Research
support was provided by Nestlé Health Science.
PD.17
Oral care knowledge and management in an irish acute hospital setting
Hill, Fiona1; Ryan Withero, Phillippa2; Connors, Siobhan2
1
Speech & Language Therapy Department, Adelaide & Meath Hospital, Dublin 24,
Ireland; 2Adelaide & Meath Hospital, Dublin 24, Ireland
Introduction
Strong evidence exists of an association between oral health and pneumonia. Poor oral
health is one factor known to increase the risk of aspiration pneumonia in conjunction
with a swallow disorder. The positive effects of good oral care on respiratory disease
and mortality are recognised. This research evaluated the current attitudes, knowledge,
and oral care practices of healthcare staff in an acute hospital in order to identify
potential areas for improvement and inform the development of evidence based oral
care management.
Method
A self administered questionnaire was completed by healthcare staff in a sample of
general medical, neurological, age related, and intensive care wards of an acute
hospital. The questionnaire addressed attitudes, clinical knowledge and training,
practices, and resources.
Results
Of 92 respondents, oral care was deemed a high (58%) or equal priority (41%) to other
aspects of personal care. 46% recognised the importance of oral care in preventing
respiratory complications. Almost one third had not received training in the assessment
(33%) and provision (27%) of oral care, and half requested initial/further training. Half
of respondents were unsure or reported that no oral care protocol existed on their ward.
60% provided oral care to patients requiring assistance more than 3 times daily.
Toothbrushes or toothpaste were not routinely used during oral care (21% and 39%
respectively) and foam sponges were used by 72% of respondents.
Discussion
Oral care is deemed a relatively high priority and is recognised as having an important
role in the prevention of respiratory disease. However, findings indicate the need for
initiatives to improve the knowledge, quality and evidence based management of oral
care in this acute hospital setting.
PD.18
Speech therapist management and pulmonary complications development in
dysphagic patients in palliative care
Gonçalves, Aline1; Nascimento, Weslania2; Barcelos, Camila1; Siqueira, Luciana1;
Guedes, Renata1; Pinto, Aline1; Netto, Irene1; Montoni, Neyller1; Carrara-de Angelis,
Elisabete1
1
Hospital AC Camargo, São Paulo, Brazil; 2Faculdade de Medicina de Ribeirão Preto, São
Paulo, Brazil
Introduction: The speech therapist intervention in patients under palliative care aims to
improve the quality of life by reducing complications. Objective: To describe the speech
therapist managements and evaluate pulmonary complications in these patients.
Material and Methods: Retrospective and descriptive study, conducted by the patient’s
chart rewiew on the Speech Pathology Departament at Hospital A. C. Camargo / SP.
Patients monitored by the Palliative Care Department in 2011 who underwent clinical
evaluation, had dysphagia diagnosis, regardless of etiology, grade, gender and type of
treatment were included. Identification data, disease history, medical treatment,
complaints, swallowing therapy, and pulmonary complications from 6 months to 1 year
after evaluation were obtained. Increased secretions, fever, pneumonia, poor general
condition, dyspnea, intubation, hospital discharge and death were considered. Results:
43 patients with mean age of 61.2 years were evaluated, the most common primary
site was esophagus (15 subjects - 35.5%). The main treatment modality was surgery,
radiotherapy and chemotherapy combination in 12 patients (32.3%). Swallowing
evaluation revealed residue in 33 (77.4%) patients, and clinical signs of
penetration/aspiration in 30 (71%), especially with liquids. Oropharyngeal dysphagia
was evident (93.6%), with mainly mechanical etiology, 26 (61.3%) and mild, 18 (41,
9%). Dysphagia management included objective evaluations, daily swallowing
evaluation with a focus on safety and oral pleasure. Discussion: Dysphagia may be
present because of anatomical or neurological impairment, leading to pulmonary
complications and changes on quality of life that can be minimized with speech therapy.
PD.19
Identification risk of aspiration pneumonia in two groups of patients with
stroke
Soria, Franciele1; Furkim, Ana Maria2; Nunes, Maria Cristina3; Pinto, Gisele4; Lange,
Marcos4; Zetola, Viviane4
1
Faculdade Assis Gurgacz, Toledo, Brazil; 2UFSC, Florianopolis, Brazil; 3UTP, Curitiba,
Brazil; 4UFPR, Curitiba, Brazil
INTRODUCTION: The speech therapist works to prevent and reduce pulmonary
complications from the management of swallowing safely and effectively (ASHA, 2004).
The objective of this study is identify the risk of aspiration pneumonia in two groups of
patients with stroke. MATERIALS AND METHODS: A prospective study at the Clinical
Hospital of Paraná in nine patients. All patients underwent clinical and functional
assessments nasolaringofibroscópica of swallowing (FEES®), (LANGMORE, SCHATZ &
OLSEN, 1988). Patients were followed for three months and divided into two groups:
first group was made speech guidance on nutrition, posture and food consistency and
second group orientation and speech therapy weekly with orofacial myofunctional
exercises (MARCHESAN & FURKIM, 2003), vocal (BEHLAU et al., 2004) and maneuvers
of rehabilitation (STEENHAGEN & MOTTA, 2006). RESULTS: Of the nine, six (66.7%)
were females and three (33.3%) were male, with ages ranging from 30 to 86 years. In
functional clinical eight (89.0%) had clinical signs of cough and nine FEES® (100.0%)
had tracheal aspiration, and one (11.0%) with silent aspiration. In relation to a
laryngeal sensitivity (11.0%) patients showed this decreased sensitivity and eight
(89.0%) sensitivity absent. Of the nine, one (11.0%) died, four (44.5%) attended the
first steering group speech therapy and four (44.5%) of the second group with
orientation and language therapy. DISCUSSION: Proper orientation speech is extremely
important for the rehabilitation of dysphagic patients contributing to the prevention of
pulmonary complications (SMITHHAMMOND & GOLDSTEIN, 2006). Although all patients
had oropharyngeal dysphagia, it was observed that there was no aspiration pneumonia
in this sample study.
PE.01
Speech and language therapy in a case of bilateral paralysis of the
glossopharyngeal after tonsillectomy
Scheeren, Betina; Motta, Ligia; Moussalle, Sérgio
PUCRS' Hospital, Porto Alegre, Brazil
Introduction: Tonsillectomy is the most common surgery performed in the pediatric
population. The most common complications are bleeding and postoperative pain, while
others may occur. Neural lesions following tonsillectomy have been little reported in the
literature and apparently rare. Case Report: A 5-year-old male child came to PUCRS’
Hospital (Porto Alegre/Brazil) complaining of difficulty in swallowing after 7 days from
tonsillectomy. He was hospitalized in order to investigate dysphagia and an enteral tube
feeding was necessary. The medical diagnosis was bilateral paralysis of the
glossopharyngeal, due to tonsillectomy. The clinical examination showed hypernasal
voice and severe dysphagia for all consistencies of food. In the Videofluoroscopic
Swallowing Studies was observed the absence of swallowing reaction. Speech-language
therapy was done through thermal stimulation, velopharyngeal and pharyngeal
exercises and Masako maneuver. At the end of 45 days of treatment the enteral tube
was removed and the oral feeding was reestablished. Discussion: The tonsillectomy
may cause irritation of the pharyngeal plexus, leading to dysphagia, a loss of
pharyngeal reflex, disorders of taste and sensitivity in the posterior third of the tongue
and speech difficulties. Conclusion: Bilateral paralysis of the glossopharyngeal nerve
after tonsillectomy seems to be a rare complication that resonated with severe
dysphagia. In this case the speech and language pathologist played a key role to
restore the patient's voice and swallowing.
PE.03
Management of feeding and swallowing disorders in infants with prader willi
syndrome: the french reference center for pws’ experience
Fichaux-Bourin, Pascale1; Diène, Gwenaëlle2; Molinas, Catherine2; Cabal-Bertomieu,
Sophie2; Tauber, Maïthé2
1
CHU Toulouse, TSA 30030, France; 2French Reference Center for PWS, Toulouse,
France
The Prader Willi syndrome is a multisystem genetic disease characterized in infancy by
diminished fetal activity, severe central hypotonia, short stature, genital hypoplasia and
failure to thrive. Today the diagnosis is realized in the first weeks after birth. Secondly,
in the absence of specific management, appears during the 2nd year of life an obesity
associated with the other endocrine anomalies probably bound to an hypothalamic
dysfunction. AIM To assess oral sensorimotor and swallowing function in infants with
Prader Willi syndrome and to manage feeding and swallowing disorders. METHOD
Suckling, feeding abilities and first interactions are monitored and scored using grid as
NOMAS and Brazelton scale and swallowing evaluation including videofluoroscopic
swallow evaluation. Psychological support and educational program, including
adaptative strategies and sensorimotor therapies are integrated in a multidisciplinary
management. RESULTS The cohort of 40 infants with PWS, followed by the French
Reference Center, showed a significant improvement in feeding abilities and a reduced
duration of enteral feeding. Moreover, the developmental trajectories seem enhanced.
CONCLUSIONS Because these results, we emphasize the need of an early management
of Prader Willi syndrome, beginning in the neonatal period. Key words: Prader Willi
syndrome, Genetics, Clinical manifestation, Early management
PE.04
A descriptive retrospective study on an interdisciplinary intervention for young
children with feeding disorders
Remijn, Lianne1; Speyer, Renee2; Holtus, Petri1; van Limbeek, Jacques3; Nijhuis-van
der Sanden, Maria4
1
Sint Maartenskliniek, Rehabilitation centre, Nijmegen, Netherlands; 2University of
Applied Sciences, Institute of Health Studies, Nijmegen, Netherlands; 3de Viersprong,
Halsteren, Netherlands; 4Radboud University Nijmegen Medical Centre, Scientific
Institute for Quality of Healthcare, Nijmegen, New Caledonia
Introduction: The purpose of this study was to present both qualitative and quantitative
therapy outcome measures of an interdisciplinary intervention for children with feeding
disorders. Methods and Material: The feeding intervention included a behavioural
programme, oral motor training, parental coaching and dietary support. Average
duration of the in-patient feeding programme was 4.3 weeks (SD 1.4 weeks).
Qualitative and quantitative food intake information was collected before intervention,
at discharge and three months after discharge. This study presents the data of 29
children (Mean 2.5 years; SD 1.4 years). The cohort contained three groups: tube-fed
(N = 12), selective food refusal by texture (N = 7) and unpredictable food refusal (N =
11). Results: Primary outcome measures were calorie intake and amount of solid food
consumed. Three months after discharge, half of the children receiving tube feeding had
changed to complete oral feeding and two children were receiving 65% oral feeding.
Although children with selective food refusal by texture made small progress during the
intervention, at follow-up they had increased their solid food intake. Children with
unpredictable food refusal increased their food intake during the intervention and were
able to maintain these gains at home. Discussion: The intensive interdisciplinary
intervention for children with various feeding problems showed good results in terms of
increased calorie and solid food intake and reduced tube feeding for all children in the
cohort except children with metabolic dysfunction.
PE.05
Enteral feeding in children with cerebral palsy and severe dysphagia.
Soria, Franciele1; Furkim, Ana Maria2; Hirata, Gisela3; Lagos, Hellen3; Santos, Rosane3;
Celli, Adriane3; Abdulmassih, Edna3
1
FAG, Toledo, Brazil; 2UFSC, Florianopolis, Brazil; 3UTP, Curitiba, Brazil
Introduction: Dysphagia in neurological disorders can lead to life-threatening
complications such as recurrent aspirations, leading to recurrent pneumonia ¹. Chronic
disturbances in swallowing result in malnutrition, dehydration, aspiration and
pneumonia. According to Ponsky and Gauderer (1980), the main indication for
gastrostomy, in daily clinical practice, is related to the administration of long-term
enteral nutrition for patients with dysphagia. The objective of this study was assess the
use of feeding tube in children with severe oropharyngeal dysphagia (with aspiration of
all consistencies in the videofluoroscopic swallowing study), over 01 year of age and
diagnosis of cerebral palsy. Material and Methods: Retrospective study through analysis
of videofluoroscopic swallowing study results and correlation with history of use of
feeding tube referred by caregiver. It was analyzed the swallowing study of 73 children
with cerebral palsy, between 0 and 14 years of age, performed at the Clinical Hospital
of Paraná, between the years 2008 and 2011. Results: From total of 73 children with
cerebral palsy evaluated at Peroral Endoscopy group at Hospital de Clinicas, 13 had
tracheal aspiration for all consistencies, medical history of aspiration pneumonia and did
not use a feeding tube. All children had low or very low weight for age. Conclusion:
Children with cerebral palsy must undergo clinical and videofluoroscopic evaluation,
attended by a speech therapist for better management and rehabilitation, preventing
recurrent pneumonia, and malnutrition.
PE.06
Correlation between general functional level and oromotor functions in
duchenne muscular dystrophy
Necati, Ediz Yilmaz1; Karaduman, Ayse2; Demýr, Numan2
1
Hacettepe University, Faculty of Health Sciences, Ankara, Turkey; 2Hacettepe
University Faculty of Health Sciences, Ankara, Turkey
Introduction: Duchenne Muscular Dystrophy (DMD) affects 1 in every 3500 live male
births. Progression of muscle weakness and leg contractures leads to decrease of
funtional level in DMD. This study examined the correlation between general functional
level and oromotor functions, also between the swallowing ability and oral speech
mechanisms in DMD. Material and Method(s): 25 subjects (mean age 10.52±3.37 years)
with DMD in variable functional level according to “Brooke Functional Classification
(BFC)”, randomly included in this study. All the subjects were 5 years and/or older age
also able to independently fed. After their BFC was scored, the speech mechanisms and
swallowing abilities were examined by clinical tools respectively Oral Speech Mechanism
Screening Examination (OSMSE-3) and Swallowing Ability and Function Evaluation
(SAFE). Result(s): Fourteen patients (56 %) were indicating physical examination
findings regarding swallowing disorders and thirteen patients (52 %) were indicating for
oral phase disorders. When the results were analyzed; positive correlation was found
between the general functional level and swallowing (p< .05). Also the scores of SAFE
and OSMSE-3 were correlated (p< .01). Discussion: Orofacial and oropharyngeal
muscle groups are involved in the progressive course of the disease. The influence of
these structures can be resulted in swallowing difficulties collateral to general functional
dependency.
PE.07
Clinical and videofluoroscopic findings of the oropharyngeal swallowing in the
genetic syndromes
Sales, André1; Cola, Paula1; Fernanda, Peres2; Adriana, Jorge2; Rarissa, Dallaqua3;
Giacheti, Célia3; Silva, Roberta Gonçalves3
1
Universidade Estadual Paulista Júlio de Mesquita Filho, Marília, Brazil; 2Unesp, Bauru,
Brazil; 3Unesp, Marília, Brazil
Purpose: To describe the clinical and videofluoroscopic oropharyngeal swallowing
findings in genetic syndromes. Methods: A descriptive study of the cross sectional
involving 15 subjects with genetic diagnosis confirmed, with eating or swallowing
complaint, ranging in age from seven months to 23 years old. It was performed clinical
and videofluoroscopic assessment of oropharyngeal swallowing. Results: The swallowing
clinical evaluation showed 73.33% of change in the sealing lip sphincter, 33.33%
decrease in laryngeal elevation, 46.66% cough after swallowing, 60% had abnormal
cervical auscultation and respiratory. Videofluoroscopic evaluation of swallowing in 60%
showed abnormalities in the oral phase of swallowing, 53.33% posterior spillage, 53.33%
residue in pharyngeal recess and 40% laryngeal penetration and laryngotracheal
aspiration. Conclusions: Considering the results we can conclude that oropharyngeal
dysphagia is part of the phenotype of different genetic syndromes in this study, being
necessary to the investigation of swallowing as a routine procedure in the diagnostic
process of these individuals. However, considering the heterogeneity and the number
even low in this sample, we suggest future studies that can map the biomechanics of
swallowing in different genetic conditions.
PE.08
Implementation of an oral-motor rehabilitation program in a department of
pediatric gastroenterology and nutrition.
Pinillos, Sergio; García, Raquel; Milá, Anna; Ortiz, Catalina; Meavilla, Silvia; Castejón,
Esperanza; Martín de Carpi, Javier; Vila, Víctor; Varea, Vicente
Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
Introduction. Oropharyngeal dysphagia (OD) is a risk for malnutrition, which is specially
important in children (stage of growth and development). The oral-motor rehabilitation
is part of nutritional therapy. We describe our experience following the implementation
of oral-motor rehabilitation program (OMRP) conducted by a speech therapist, in a
department of pediatric gastroenterology and nutrition (PGN). Material and methods.
Prospective study of patients included in the OMRP from September 2010 to February
2012. Distribution by sex, age, underlying disease, therapeutic group and overall
results.Results. 106 patients included, 68 male (64%). Average age 3 years and 2
months (2 months - 17 years). Underlying disease: neurological disease (cerebral palsy,
global developmental disorder, traumatic brain injury, cerebral vascular and tumoral
disease) n= 64 (60%), non neurological disease (congenital heart disease, functional
maturation disorder, craniofacial anomalies, airway abnormalities, others) n=42 (40%).
According to the rehabilitation group therapy: Group (G)1: chewing disorders (n= 12,
11.5%), G2: Return to oral feeding from nasogastric tube or gastrostomy (n= 23,
21.5%), all with oral hypersensitivity, G3: moderate-severe oral-motor dyspraxia (n=
54, 51%), G4: Others (n= 17, 16%). The number of sessions varies according to
availability and the type and severity of involvement. The overall trend is positive in 95%
of children in the first 2 months of treatment, faster and better in groups 1 and 2.
Conclusions. The addition of a speech therapist and an OMRP in a department of PGN,
first experience in our country, contributes positively to the nutritional evolution of the
child with OD.
PE.09
Oropharyngeal dyspgahia in children. Evaluation and treatment in a specific
unit of a department of pediatric gastroenterology and nutrition
Pinillos, Sergio; García, Raquel; Meavilla, Silvia; Gutiérrez, Alejandra; Milá, Anna;
Márquez, Adela; Trías, Marta; Alcaraz, Ricard; Ortiz, Catalina; Varea, Vicente
Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
Introduction. Oropharyngeal dysphagia (OPD) affects 20% of children, 75-90% in
children with neurological disability. Can lead to malnutrition and chronic lung disease,
both of particular importance in childhood. In 2008 was established a swallowing
disorders unit (SDU) in the department of pediatric gastroenterology and nutrition of
our center (first experience in our country). Material and methods. Description of the
general characteristics of our SDU: staff, patients, evaluation methods, treatment and
rehabilitation. Results. The unit consists of 2 physicians specializing in gastroenterology
and nutrition, 2 speech therapists, 2 dietitians, 2 nurses and a radiology technician. 376
children have been evaluated, 73% (n = 274) with neurological diseases of varying
etiology and severity (cerebral palsy, global developmental disorder, neuromuscular
disease, acquired brain injury) and 27% (n = 102) with non-neurological diseases
(congenital heart disease, functional disorder, craniofacial anomalies, airway
abnormalities, others). 256 videofluoroscopy have been performed (mean age 5 years
and 6 months), result: severe dysphagia in 74 (29%), moderate in 100 (43%), mild /
no dysphagia in 71 (28%). The observation of the normal intake is very important given
the difficulty (little cooperation of the child) to carry out the test volume viscosity.
Placement of a gastrostomy indicated in 52 children. 107 children were included in an
oral-motor rehabilitation program. Discussion. OPD in children is a common condition,
especially in children with neurological and craniofacial anomalies. The observation of
the intake is very important in children. Videofluoroscopy is the gold standard
examination in the assessment. It is necessary to standardize protocols.
PE.10
The value of food refusal to infants swallowing disorders.a retrospective
analysis of 11 cases.
Marmouset, Franck; Pateron, Bénédicte; Moriniere, Sylvain
Service ORL Hopital Bretonneau, Tours, France
Introduction : Food refusal is a common problem in pediatric practice. However, it
seems to be underestimated as an oropharyngeal dysphagia evidence. Our purpose was
to identify this symptom and to try to understand its significance. Materials and
Methods : Retrospective analysis. 11 children (age range 11 days – 7,25 years; mean
1,06 year ; 6 females and 5 males) with aspirations and showing no nausea underwent
a fiberscopic swallowing evaluation in a pediatric university hospital between february,
2011 and may, 2012. A chart review was done, to determine the relationship between
food refusal, and : the age and sex of children, origin of dysphagia, or inhalation
pneumonia. Results : In the food refusal group (7 infants) we found one pneumonia,
versus one pneumonia in the other group (4 infants). No relationship was found
between the age, sex and kind of neurological injury and the belonging to one of the
groups. Discussion : We know few about food refusal in pediatrics. Prima facie, food
refusal seems to avoid inhalations and therefore to be an airway protection. However,
in some cases of our study, food refusal appeared and disappeared together with
swallowing disorders and was specific of a dangerous texture. A larger number of cases,
in a future prospective study, will help us 1)to elucidate the links with pneumoniae and
2)to understand the occurrence of food refusal and the diversity of reactions for similar
neurologic impairment.
PE.11
Severity of dysphagia and intake of nutrients in post stroke individuals
Mituuti, Claudia1; Silva, Tatiane1; Silva, Marcela1; Corbini, Lia2; Santos, Adriane3;
Berretin-Felix, Giedre1
1
Bauru Dental School - University of Sao Paulo, Bauru, Brazil; 2SORRI Rehabilitation
Center, Bauru, Brazil; 3Sagrado Coraçao University, Bauru, Brazil
Introduction: Dynamic swallowing changes may result in modification of diet
consistencies, with wrong alimentary choices. It may cause poor nutrition characterized
by the nutrients excess or deficiency. The purpose of this study was to verify the
relation between level of adequacy nutrients of diet and the dysphagia severity in
elderly post stroke individuals. Material and Methods: 22 post stroke elderly individuals
were evaluated (12 men and 10 women) and had average age of 71,86 years. The
intake of nutrients was analyzed from food recordatory of 24 hours associated to replica
foods applied on different days of week. The composition of diet micronutrients was
calculated using the Nutrilife 7.4 software. The alimentary consume of macronutrients
(carbohydrates, lipids and proteins), and micronutrients (A, C, E, B12 vitamins, Folate,
Calcium, Iron, Selenium, Zinc) was evaluated. The calculation based on the Dietary
Reference Intake was used to adapt the intake of nutrients and energy. Furthermore,
the individuals were submitted to swallowing videoendoscopic evaluation with the
consistencies liquid, pasty and solid to characterize the dysphagia severity according to
the Dysphagia Outcome Severity Scale (DOSS). Results: The Spearman correlation test
showed statistically significant difference (p=0,03) that the minor selenium intake
shows higher dysphagia severity. Discussion: The severity of dysphagia interfered on
intake of selenium font foods in patients post stroke. It´s necessary new researches to
prove this correlation, because studies suggests that selenium deficiency is related to
weakness, muscular sensitivity and neurological disturbances.
PE.12
Severity dysphagia and oral intake comparison between healthy elderly and
post stroke elderly
Mituuti, Claudia1; Silva, Marcela1; Bentim, Claudia2; Berretin-Felix, Giedre1
1
Bauru Dental School - University of Sao Paulo, Bauru, Brazil; 2SORRI Rehabilitation
Center, Bauru, Brazil
Introduction: On adult and elderly population, the dysphagia is commonly associated to
stroke. In view of occurrence of presbyphagia in this population, the purpose of this
study was to compare the dysphagia severity between health elderly individuals and
post stroke individuals in chronic period of involvement. Material and Methods: 30 post
stroke elderly individuals (experimental group – EG), with aged between 61 and 90
years (average 73 years), with lesion time between 8 months and 9 years, 15 men and
15 women, and 15 health elderly individuals (control group – CG), similar in gender and
age to the EG individuals. The individuals were submitted to endoscopic evaluation of
swallowing of solid, liquid and pasty food to characterize the dysphagia severity and
oral intake through the Functional Oral Intake Scale (FOIS). Results: There was higher
occurrence of moderate dysphagia for the EG and mild to moderate dysphagia for the
CG, with statistical differences between groups just to liquid (p=0,01). About the oral
intake, there were no statistical differences between groups (p=0,35). Discussion: The
performance of swallowing was similar to the health elderly individuals and chronic post
stroke individuals to the consistencies pasty and solid, as well as to the oral intake.
However, was higher dysphagia severity on EG to the liquid. These findings contributes
to the diagnosis and establish a prognosis in the treatment of oropharyngeal dysphagia
in elderly chronic post stroke.
PE.13
Evaluation of nutritional status in patients with dysphagia due to stroke
Miranda, Rúbia; Santos, Rafaela; Pacheco, Aline; Dantas, Roberto; Pontes-Neto,
Octávio
Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, Brazil
Introduction: Swallowing is an essential physiologic process for body nutrition and
hydration. The safety and efficacy of swallowing dependent on integrity of the central
nervous system and other structures involved in this process. Any difficulty in the
dynamics of swallowing is called dysphagia, which can lead to complications such as
aspiration pneumonia and changes in nutritional status. Dysphagia occurs in 45-65% of
cases of after stroke, and 6% to 62% of stroke patients show signs of malnutrition. The
aim of this investigation was to characterize nutritional status of a group of individuals
with dysphagia after stroke. Material and Methods: According to inclusion and exclusion
criteria, we included in the research patients with diagnosis of stroke confirmed by brain
imaging examinations admitted to a tertiary university hospital from August 2011 to
January 2012 who had dysphagia. The screening test Mini Nutritional Assessment ®
(MNA ®) was applied to all selected patients at an average of one month after stroke,
in order to check if they were at risk of malnutrition. Results: Twenty seven patients
participated in the study. Of these, eleven (40.7%) were classified as normal nutritional
status, nine (33.3%) had nutritional risk and seven (25.9%) were classified as
malnourished. Discussion: We observed signs of malnutrition in 25.9% of patients with
stroke and dysphagia. Studies are required to evaluate the impact of nutritional status
in the patients prognosis.
PE.15
A transatlantic comparison of acute dysphagia services
Newman, Roger1; Long, Tony2
1
Lancashire Teaching Hospitals NHS Trust, Preston, United Kingdom; 2University of
Salford, Salford, United Kingdom
INTRODUCTION This is the first study to directly compare acute dysphagia service
provision between the UK and the US. The aims of the study were (1) to examine if the
acute dysphagia services offered to patients varied between the UK and the US; (2) to
determine clinicians’ perceptions of their own service and that of their transatlantic
counterparts; and (3) to ascertain the source of any variation. MATERIALS AND
METHODS An online survey was created and distributed to randomly allocated teaching
hospitals in the UK and in the US. Speech-language pathologists working with acute
dysphagia responded anonymously and results were collated and directly compared to
one another, showing both similarities and variation. RESULTS AND DISCUSSION
Variability was high, with the US having on average 0.95 whole time equivalent more
clinicians per hospital than the UK; an increase in the number of new patients they are
able to examine and the number of times they review their existing patients, while the
UK had significantly increased waiting times with no patient being assessed on the
same day as referral, compared to 63.6% of US responses. Notable variation was also
seen in objective/instrumental assessment, with the majority of US patients receiving
videofluoroscopy/FEES. Finance was found to be at the root of the variation, but the US
was seen to provide a more cost-effective service. However, not all US patients were
able to access it due to a potential lack of appropriate insurance. This is something that
the NHS prevents, but in doing so it increases waiting time for service response. The
study creates a greater understanding of transatlantic strengths and weaknesses, so
each country can learn from one another, and improve their own acute dysphagia
services.
PE.16
Transoral robotic surgery – total laryngectomy new technique to restore
swallowing function in case of laryngeal incompetency
Lawson, Georges1; Bachy, Vincent1; Mendelsohn, Abie2; Remacle, Marc1; Rijckaert,
Myriam1; Degrelle, Isabelle1; Van Der Vorst, Sebastien1
1
Universite Catholique de Louvain CHU de Mont Godinne, Yvoir, Belgium; 2David Geffen
School of Medicine at UCLA, Los Angeles, United States
INTRODUCTION: Performing salvage total Laryngectomy after failure of organ
preservation chemo radiation or laryngeal incompetency is related to sever post
operative complication and dysphagia. We assessed, in this study, the feasibility of
performing transorale Total Laryngectomy with robotic instrumentation. MATERIALS &
METHODS: Transorale robotic surgery (TORS) was performed on 6 consecutive human
patients with Laryngeal Squamous cell carcinoma previously treated by organ
preservation protocol. This study was approved by our institutional ethical comity.
Fiberoptic endoscopic evaluation of swallowing (FEES) was performed on post operative
day two, four and height to guide the rehabilitation process and timing for modified
barium swallow study (MBSS). RESULTS: After conventional tracheostomy, all
procedures were completed robotically.The mean operative time was 257 minutes.
There were no intraoperative or postoperative complications or surgical mortality
related to the use of Robot da Vinci system. None of the patient requires pharyngeal
reconstruction with local or free flap. No pharyngeal stricture was observed. Discussion:
Intraoral approach for total Laryngectomy offers a number of benefits over the
traditional approach. The direct view allows for maximal mucosa sparing. TORS incision
allows for a substantial improvement in pharyngeal defect size. This results in a linear
horizontal closure mitigating the concerns for ischemia while reducing the possibility of
pharyngeal shelf and neopharyngeal diverticula formation. CONCLUSION: To date, we
have performed TORS-TL for both oncologic and functional indications. The goal of the
present report is to share the surgical protocol successfully utilized and clinical
experiences; so conclusive data may be gathered
PE.17
Surgical treatments for intractable aspiration
Nito, Takaharu1; Imai, Naoko2; Yamauchi, Akihito1; Ueha, Rumi1; Yamasoba, Tatsuya1
1
University of Tokyo hospital, Bunkyo-ku, Japan; 2University of Tokyo hosipital, Bunkyoku, Japan
Introduction: Surgical treatments for intractable aspiration which result in crisis of life
has been popular. The pourpose of this study is to elucidate the efficiency of the
surgical treatments. Material and Methods: The subjects are 42 patients who underwent
the surgical treatments from 2006 to 2011. Retroseptive chart and questionnaire for
patients and their families was reviewed. Results: 15 patients had amyotrophic lateral
sclerosis, 8 patients had multiple system atrophy, 5 patients had brain vascular disorder,
2 patient had Parkinson disease and 12 patients had other diseases. Thirty patients
underwent laryngeal closure. Ten patients underwent laryngotracheal separation or
diversion. Two patients underwent total laryngectomy. Twenty seven patients and their
families answered the questionnaire. Eight patients became able to take general or soft
diet orally. Eighteen patients do paste or liquid for pleasure. One patient took nothing
orally. Patients with slow progressive or stabilized diseases kept oral intake for over one
year. However, patients with fast progressive diseases had a decreased ability of oral
intake. Twenty four families and 21 patients answered “satisfy” or “slightly satisfy” to
the question “Do you satisfy the result of the surgery?” Discussion: It is possible for
almost all the patients who underwent the surgical treatment for intractable aspiration
to take food or liquid orally to a varying degree. Oral intake can be one of the few
pleasure for the patients with decreased ADL and no phonatory function. Surgical
treatments for intractable aspiration is effective and should be consideration.
PE.18
Staff training and audit: inter-related components of dysphagia management
Walsh, Mary
Health Service Executive, Dublin, Ireland
Introduction: Dysphagia management involves inter-related components and a
feedback-action loop between them may improve effectiveness: Assessment and
diagnosis; Unambiguous care-plans; Effective communication/action of MDT; Training
and support of MDT; Audit and incident reports.
Materials and Methods: In 2010 following nine swallow –related incidents, the SLT
Department and the Risk Manager rolled out a staff training module. Aims: 1. To raise
awareness across the MDT of the serious consequences from safety/ quality of life
perspectives of non-compliance of swallowing recommendations. 2. To foster a culture
of increased ownership/responsibility in each MDT member.
In Nov 11, SLTs and dietitians jointly undertook a two-part Audit on Texture Modified
Diets and Fluids investigating: 1. Provision by Catering of diet options that matched the
national descriptors for texture modified diets. 2. Compliance of diet and fluids given to
patients/residents with what SLT had prescribed.
Results: • 116 MDT staff members have received training. Comments and reports by
participants and clinical observations indicated improved awareness and ownership of
dysphagia by each MDT member. • There was an average audit compliance rate of 76%
diet and 75% fluids. • Following the audit, most of the Catering recommendations have
been implemented and specific ward recommendations were incorporated into tailored
ward-based training.
Discussion: The audit is to be repeated later in 2012. Clinical observation suggests that:
1. Training and audit have positively affected case management in this setting, 2.
Effective Dysphagia management needs a broad systemic as well as individual
perspective. 3. Further research in this area is needed.
PE.19
The deglutition profile
Anne, hiernaux
CHU Liège, Esneux, Belgium
After seventeen years in the neurologic rehabilitation unit, it’s still difficult to make the
nursing and the families understand why a patient can't eat or drink normally. So I
decided to characterise the different problems of the patients with what I call "the
deglutition profile". This is addressed to the family and the nursing. It helps us too to
follow our patients’ progresses. With the help of two students, we create a
macrostructure on Excel Windows. We can choose the deficits, the capacity of
deglutition, characterize the deglutition, the risk and specify different types of help. We
then print the document and put it in a file in the patient's bedroom. The different
profiles allow everyone to see the difficulties and the progresses when the profile
changes.The more important deficits are marked in red and the progresses are marked
in green. This tool is appreciated by the families and helps the nursing to understand
the deficits and the progression about alimentation.
Author’s Index
Czechowski, Aliana
Degrelle, Isabelle
Delacroix, Laurence
Remacle, Marc
A Dedivitis, Rogério
A F Castro, Mario
Abdulmassih, Edna
Adriana, Jorge
Aere, Christina
Albini, Rejane
Alcaraz, Ricard
Aljibe, A.
Aloy, Andreu
Alsanei, Woroud
Alvarado, Martha ligia
Alvarez, Antonio
Alves da Silva, Marcela Maria
Amaki, Nobuko
Anne, Hiernaux
Antolin, Marta
Arreola, Viridiana
Arroyo Aljaro, Ramon
Ascanio, Gabriel
Atac, Murat
Avdyunina, Irina
Aviñó, Conxa
Bachy, Vincent
Bader, Peter
Baijens, Laura
Bao, Pilar
Barcelos, Camila
Barcelos, Irene Harumi Kamata
Barreiro, Soledad
Barritt, Andrew
Bartolini, Stefano
Bates, Grant
Bates, James
Bejer, Joke
Belmonte, Roser
Bentim, Claudia
Bergström, Liza
Beris, Alexandros
Berretin-Felix, Giedre
Beseler, R.
Beutter, Patrice
Bigenzahn, Wolfgang
Bistuer Lacarra, Anna
Bloem, Bastiaan
Bodechtel, Ulf
Bogaardt, Hans
Bohlender, Joerg
Boiron, Michèle
Bonsangue, Valentina
Borges de Oliveira, Maria Cristina
Boza, Roser
Brito-de la Fuente, Edmundo
Busch, Roberta
C Anacleto, Andrea
Cabal-Bertomieu, Sophie
Cardenete, Joana
Cardona, Daniel
Carrara-de Angelis, Elisabete
PD.10
04.03, PE.16
04.03
04.03, PE.16
PB.10
PB.10
PA.03, PE.05, PA.12
PE.07
01.05
PA.08
PE.09
PB.16
PA.02
13.01
PD.05
PB.09
PB.04
PC.17
PE.19
PB.09
01.02, 05.03, 13.03
PB.15
13.02
06.03
08.06
PC.18
04.03, PE.16
04.05, 08.07
08.10, 09.04
06.05, PA.02
PD.18
10.05
PA.17
PC.19
PC.06
03.04
03.04
03.01
10.10
PE.12
01.01
10.07
PB.04, PC.10, PE.11, PE.12
PB.16
PD.07
09.03
PB.15
PB.11
PD.12
08.10, PC.02
06.02, 12.02
PD.07
10.08
PA.09
PD.05
13.02
PB.03
PB.10
PE.03
PD.15
PD.15
PD.18
Carrión, Silvia
Carrión Pérez, Franscisca
Cassiani, Rachel
Castejón, Esperanza
Castiglioni, Kristina
Catalan, Natalia
Ceballos-Baumann, Andres
Celli, Adriane
Cengýz, Mustafa
Ceriani, Eleonora
Chen, Jianshe
Chernikova, Lyudmila
Chiarella, Sandra
chiarello, Giulia
Cichero, Julie
Ciurana, Ana
Ciurana, Ana M
Clavé, Pere
Clemente, Ivet
Cobo, Marivi
Cocho, Dolores
Cola, Paula
Colaço, Teresa
Connors, Siobhan
Constantinidis, Jiannis
Constantino, Daniela
Corbini, Lia
Costa, Cintia Conceição
Crespo, Agrício Nubiato
Cristina Pires, Elaine
Curran, Prof Aongus
da Costa, Saakje
Dagdilelis, Lukas
Daimon, Takashi
Dantas, Roberto
De Bodt, Marc
De Pourcq, Jan Thomas
Demir, Numan
Denk-Linnert, Doris-Maria
Deslangle, Valentine
Desuter, Gauthier
Devuyst, Vinciane
di pede, chiara
Diène, Gwenaëlle
Domen, Kazuhisa
Dorneles, Diego
Downes, Susan
Downey, Darragh
Duan, Jingming
Duarte, E.
Duarte, Enrique
Duarte, Esther
Dziewas, Rainer
Eberle, Silvia
Egea, Natalia
Ejarque, Judith
Ende, Franziska
Enderby, Pamela
Escalada, Ferran
Exarhakos, Georgios
Fàbregas, Cristina
Fairfield, Carol
farneti, daniele
05.03
PD.06
03.03
PE.08
06.02
02.01
03.02
PA.12, PE.05
PC.08
06.03
13.01
08.06
PD.05
PD.02
05.02, 10.04, PD.16
PA.01
PD.14
01.02, 05.03, 13.03, PD.14
PC.18
06.05, PA.02
06.05, PA.02
PE.07
10.06
PD.17
09.01
PA.06, PC.12
PE.11
PB.06, PC.12
10.05
PA.09
09.02
02.04, 10.02
13.04
12.04
03.03, PB.02, PB.12, PE.13
04.02, 08.04, PV.07
PD.15
02.02, PA.18, PC.08, PC.11, PE.06
09.03
PC.01
PC.01
04.03
10.08
PE.03
12.04
PB.06, PC.12
09.02
12.01
06.02
PB.16
PB.09
PD.05
01.04, 03.01
01.05
02.01
10.09
PD.12
PA.05, PC.15
10.10
10.07
PA.01
PA.05
PD.02
Fattori, Bruno
Fávero, Talita
Febrer, Anna
Fernanda, Peres
Feussner, Hubertus
Fichaux-Bourin, Pascale
Figueiredo Magalhães, Fabiani
Fonts, Nuria
Fortes Ferreira, Dario
Fossas, Pilar
Francois, Sylvie
Fujino, Ayumi
Fujiu-Kurachi, Masako
Fujiwara, Shigehiro
Fullerton, Ken
Furkim, Ana Maria
Furuya,, Junichi
G Pfutzenreiter, Élio
G Portas, Juliana
Gallegos, Crispulo
Garcia, M.
García, Gemma
García, Raquel
García, Rut
García Montes, Inmaculada
Garin, Noe
Garnica, Almudena
Garrido Fernandez, P.
Gazulla, Dolores
genovese, elisabetta
Ghannouchi, Ines
Ghedini Brasolotto, Alcione
Giacheti, Célia
Gil, R.
Gill, Lyndsey
Ginocchio, Daniela
Gonçalves, Aline
Gonçalves, Caren Meneghetti
Grand, Stephane
Greene, Zelda
Guedes, Renata
Guillén-Solà, Anna
Guns, Cindy
Gutiérrez, Alejandra
Hägg, Mary
Hakkesteegt, Marieke
Hamacher, Christina
Hamdy, Shaheen
hammoudi, karim
Hartelius, Lena
Heijnen, Bastiaan J.
Herentrey, Klaus
Hey, Christiane
Hill, Fiona
Hirata, Gisela
Hoetzenecker, Konrad
Holtus, Petri
Homs, Isabel
Hori, Kazuhiro
Ickenstein, Guntram W.
Imai, Naoko
Ina, Nitschke
Inkina, Anna
PC.06
05.01, PA.06
02.01
PE.07
PD.03
PE.03
PB.04
PD.15
PA.09
PA.01
PC.01
PC.17
12.02
12.02
PC.16
PA.03, PA.08, PA.12, PA.15, PD.08, PD.10, PD.19, PE.05
08.05
PB.10
PB.10
13.02
10.09
02.01
02.01, PE.08, PE.09
02.01
PD.06
PD.15
PB.07
PA.10
PA.17
PD.02
08.08
PB.04
PE.07
PB.16
PB.08
06.03
PD.18
PD.01
PV.04
02.03
PD.18
10.10, PD.05
04.02, 08.04, PV.07
PE.09
PC.05, PC.13
PC.02
01.04
08.03, 12.01
PD.07
01.01
08.10
05.04
01.05
PA.16, PD.17
PA.12, PA.15, PE.05
09.03
PE.04
06.05, PA.02
12.02
PD.12
08.09, PE.17
12.02
08.06
Isenmann, Stefan
jalilian, yasaman
Jaume Bauza, Gabriel
Jayasekeran, Vanoo
Kalf, Hanneke
Kamakura, Yayoi
Kaneto, Taizo
Karaduman, A. AyÞe
karaduman, ayse
Kaspar, Kala
Kist de Mello, Renato José
Kjaersgaard, Annette
Klepetko, Walter
Knerr, Ylva
Knightingale, Julie M.
Koetsenruijter, Krista
Kubo, Letícia
Lagos, Hellen
Lange, Benjamin
Lange, Marcos
Lawson, Georges
Ledl, Christian
Li, Bingjie
Long, Tony
Lopes, Inês
Lopez Garcia, Carme
Luecking, Christoph
Maciel, Antonio Carlos
Macri, Marina
Maeda, Yoshinobu
Mancopes, Renata
Mangues, Maria Antonia
Marchese Ragona, Rosario
Marco, Ester
Marie, Jean Paul
Marmouset, Franck
Marquez, Jorge
Márquez, Adela
Martin, Wendy
Martín de Carpi, Javier
Martínez Serrano, Luz
Mas, Pilar
Masiero, Stefano
Matsui, Toshihiro
McCurtin, Arlene
McLaughlin, carolee
McMahon, Barry
Meavilla, Silvia
Meisel, Andreas
Melià, Sussagna
Mello, Fernanda
Mendelsohn, Abie
Merino, F.
Merino, Francisco
Michou, Emilia
Milá, Anna
Minagi, Shogo
Mion, Marta
Miranda, Rúbia
Mistry, Satish
Mituuti, Claudia
Molfenter, Sonja
Molinas, Catherine
PD.12
PD.13
12.05
08.03
PB.11
PC.17
12.04
02.02, PA.18, PC.08, PC.11
PE.06
05.04
PD.01
06.04
09.03
04.05, 08.07
10.03
08.10
PB.12
PA.12, PE.05
01.05
PA.08, PD.08, PD.19
04.03, PE.16
04.05, 08.07
08.02
PE.15
10.06
PB.15
03.02
PD.01
PA.08
12.02
05.01, PA.06, PB.06, PC.12
PD.15
10.08
10.10, PD.05
08.08
PD.07, PE.10
13.02
PE.09
10.01
PE.08
PA.07
06.05, PA.02
10.08
12.04
PC.14
PC.16
04.04
02.01, PE.08, PE.09
PD.12
PA.02
PB.06, PC.12
04.03, PE.16
PB.16
PB.09
08.03, 12.01
02.01, PE.08, PE.09
08.05
10.08
PB.02, PE.13
08.03, 12.01
PC.10, PE.11, PE.12
06.01
PE.03
Molinuevo, José Luis
Moller Parera, Mercedes
Momose, Yumiko
Montagut Colomer, Núria
Monteis, Rosa
Montoni, Neyller
Monzani, Anna
Moral, P.
Moreno, I.
Moriniere, Sylvain
Motta, Ligia
Mourão, Lucia Figueiredo
Moussalle, Sérgio
Mozzanica, Francesco
Mukherjee, Rajat
Mulazani Maria, Camila
Müller, Rainer
Muniesa, Josep Mª
Muñoz, Esteban
Muñoz de Escalona, Teodosia
Nagai, Miki
Nakajima, Junko
Nakane, Ayako
Nart, José
Nascimento, Weslania
Necati, Ediz Yilmaz
Netto, Irene
Newman, Roger
Newman, Roger D.
Nicholson, Timothy
Nielsen, Lars Hedemann
Nijhuis-van der Sanden, Maria
Nissen, Lisa
Nito, Takaharu
Nogueira, Dália
Nohara, Kanji
Nozaki, Sonoko
Nunes, Maria Cristina
O'Donnell, Colm PF
Oelenberg, Stefan
Oliveira, Silvia
Ono, Takahiro
Ortega, Omar
Ortiz, Catalina
Ottaviani, Francesco
Otto, Ferdinand
Oudhuis, Lizette
Ozawa, Shogo
P Bohn, Nathaniele
Pacheco, Aline
Pagliotto da Silva, Amanda
Paiva, Deborah Brandão
Palomeras, Ernest
Pantev, Christo
Papadopoulou, Soultana
Park, Jin-Woo
Parra, Carlos
Pastor, Bibiana
pastore, antonio
Patat, Frédéric
Pateron, Bénédicte
Pavlidou, Elena
Perez, Gemma
PA.17
PB.15
PC.17
PA.17
PA.01
PD.18
06.03
PB.16
PB.16
PD.07, PE.10
PE.01
10.05
PE.01
06.03
01.02, 13.03
05.01, PA.06
PD.12
10.10
PA.17
PA.10
PA.19
08.05
08.05
PD.14
03.03, PB.12, PD.18
PE.06
PD.18
PE.15
10.03
10.04
06.04
10.02, PE.04
05.02
08.09, PE.17
10.06
08.05
12.04
PA.08, PD.08, PD.10, PD.19
02.03
01.04
PD.10
08.05, 12.02
05.03, PD.14
PE.08, PE.09
06.03
PA.04
05.05, PB.18
08.05
PB.10
PB.02, PE.13
PA.09
10.05
PA.01
03.01
10.07
08.01, PC.09
PD.14
10.09
PD.02
PD.07
PE.10
09.01
PA.02
Pérez Ureña, Mª Belén
Pilz, Walmari
Pinillos, Sergio
Pinto, Aline
Pinto, Gisele
Ploumis, Avraam
Pokieser, Peter
Pontes-Neto, Octavio
Potter, Chris
Pou, Marina
Pownall, Susan
Pozuelo Calvo, Rocío
Pradas, Ana
Pradon, Emmanuel
Printza, Athanasia
Prof. Dr. Stoever, Timo
Puech, Michele
Pujol, Gemma
Radhakrishnan, Chandramouli
Raidhan, Aisha
Rarissa, Dallaqua
Rechenmacher-Strauß, Julia
Regan, Julie
Reichmann, Heinz
Reis, Elizabeth
Remijn, Lianne
renzetti, antonella
Rijckaert, Myriam
Rion, Olga
Roca, Maria
Rodenstein, Daniel
Rodriguez Moreno, Sofía
Rodriguez-Villalba, Rosana
Rofes, Laia
Roffe, Christine
Rombaux, Philippe
Romea, Mayse
Rommel, Nathalie
Roquer, Esther
Ros, Rosalia
Rubio, Cecilia
Ryan Withero, Phillippa
S Ferreira, Alessandra
S Queija, Débora
Sabaté, Rosa
Sagalés, Maria
Sakellariou, Victoria
Sales, André
Salinas, Martin
Santos, Adriane
Santos, Carla
Santos, Rafaela
Santos, Rosane
Sara, Boroumand
Scheeren, Betina
Schindler, Antonio
Sdravou, Katerina
Sebastian, Marisa
Sebastián, Marisa
Selivanov, Vladimir
September, Cindy
Serel, Selen
Serra, Jordi
PD.06
09.04
02.01, PE.08, PE.09
PD.18
PA.08, PD.08, PD.10, PD.19
10.07
PA.04
PB.02, PE.13
03.04
06.05, PA.02
PC.15
PD.06
PD.14
05.04
09.01
01.05
PV.04
PA.02
05.02
05.02
PE.07
09.03
04.04
PD.12
10.06
10.02, PE.04
PC.06
04.03, PE.16
PB.07
05.03
PC.01
PD.06
12.05
01.02, 13.03
PA.05
PC.01
02.01
04.04
PB.07
PB.09
PB.09, PB.16
PD.17
PB.10
PB.10
PA.02
06.05, PA.02
PB.14
PE.07
13.02
PE.11
03.03
PE.13
PA.03, PA.12, PA.15, PD.10, PE.05
12.02
PD.01, PE.01
06.03
13.04
PD.14
PA.01
08.06
10.04
02.02, PA.18, PC.08, PC.11
06.05, PA.02
Serrano, Estela
Shadmehr, Azadeh
Silva, Marcela
Silva, Marta
Silva, Roberta Gonçalves
Silva, Tatiane
Silveira Santos, Rafaela
Simons, A. Janine
Siqueira, Luciana
Sjölund, Bengt H.
Sliwinski, Edward
Smithard, David
Smyth, Heather
Soler, Núria
Soliman, Mohamed
Sonzini, Giulia
Soria, Franciele
Speyer, Renée
Steadman, Kathryn
Steele, Catriona
Suntrup, Sonja
Suttrup, Inga
Svensson, Per
Tack, Jan
Takahashi, Koji
Takase, Érica Mayumi
Takaya Paiva, Cora Sofia
Talebian, Saeed
Tamine, Kenichi
Taniguchi, Hisashi
Tantiñà, Silvia
Tauber, Maïthé
Tegou, Georgia
Teismann, Inga
Teive, Helio
Tejero, Marta
Tibbling, Lita
Tiemi Mituut, Cláudia
Tobed, Marc
Tohara, Haruka
Totta, Tatiane
Triaridis, Stefanos
Trías, Marta
Trindade, Bruna
Úbeda, Amparo
Ueha, Rumi
Uroz, A.
Valles, Esther
Vallons, Katleen
Van den Steen, Leen
Van Der Vorst, Sebastien
van Limbeek, Jacques
Van Nuffelen, Gwen
Van Vlasselaer, Kristin
Vanderwegen, Jan
Varea, Vicente
Vasant, Dipesh
Verin, Eric
Vicente, William
Vidyasagar, Rishma
Vila, Rosa
Vila, Víctor
Vith, Ursula
PD.14
PD.13
PC.10, PE.11, PE.12
PA.14
PE.07
PE.11
PB.02
01.03
PD.18
06.04
05.05, PB.18, PB.19
PA.05, PB.08, PC.19
05.02
06.05
PB.08
06.03
PA.03, PA.08, PA.12, PA.15, PD.08, PD.10, PD.19, PE.05
10.01, 10.02, PC.02, PE.04,
05.02
04.01, 06.01, PD.16
03.01
01.04, 03.01
01.01
04.04
08.05
10.05
PB.04
PD.13
12.02
08.05
PA.02
PE.03
13.04
03.01
PA.03
10.10
PC.05, PC.13
PB.04
PC.18
PA.11
PB.04
09.01
PE.09
05.01, PA.06
PB.09
08.09, PE.17
PA.10
PB.15
05.05, PB.18
08.04, PV.07
PE.16
10.02, PE.04
04.02, 08.04, PV.07
PB.01
04.02, 08.04, PB.01, PB.05, PV.07
02.01, PE.08, PE.09
08.03
08.08
13.02
12.01
PA.01
PE.08
12.02
Wada, Satoko
Wagner-Sonntag, Edith
Walker, Margaret
Walsh, Mary
Walshe, Dr Margaret
Walshe, Margaret
Warnecke, Tobias
Wiggam, Ivan
Williams, Steve
Winters, Stuart
Woisard, Virginie
Yakut, Yavuz
Yamasoba, Tatsuya
Yamauchi, Akihito
Yoshikawa, Hiroo
Yoshikawa, Mineka
Zanata, Isabel
Zanello, Marco
Zarcero, Silvia
Zetola, Viviane
PA.11
03.02
PB.08
PE.18
09.02
02.03, 04.04, 13.04, PB.14
01.04, 03.01
PC.16
12.01
03.04
PV.04
PC.08
08.09, PE.17
08.09, PE.17
12.04
08.05
PA.15, PD.10
PC.06
PD.14
PD.08, PD.19