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1
Department of Radiology, University of Vienna, Waehringer Guertel 18-20,
A-1090 Vienna, Austria.
2
Department of Otorhinolaryngology, University of Vienna, Waehringer Guertel
18-20, A-1090 Vienna, Austria
Received August 17, 1999;
accepted after revision October 20, 1999.
Supported by the Ludwig Boltzmann Institute for Radiologic Tumor
Research.
Abstract
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SUBJECTS AND METHODS. Twenty-one patients (16 men, five women; mean age, 66 years) who presented with clinical signs of aspiration after long-term intubation (mean duration, 24.6 days) underwent videofluoroscopy. They were analyzed for functional abnormalities of the tongue, soft palate, epiglottis, hyoid and larynx, pharynx, and the upper esophageal sphincter. We assessed the presence or absence of aspiration, the type of aspiration (pre-, intra-, and postdeglutitive), and a spectrum of other swallowing abnormalities.
RESULTS. There were 18 patients (86%) with radiologically proven aspiration. In another patient only laryngeal penetration occurred. There were 11 combinations of pre-, intra-, and postdeglutitive aspiration. Predeglutitive aspiration was predominant and present in 52% of our patients. We found functional abnormalities of the tongue in 48%, of the soft palate in 10%, of the epiglottis in 48%, of the pharynx in 71%, and of the upper esophageal sphincter in 24%.
CONCLUSION. Patients who are symptomatic after undergoing long-term intubation do not develop a specific type or pattern of swallowing dysfunction or aspiration, but show a large variety of aspiration types and associated swallowing disorders. Nevertheless, videofluoroscopy has the ability to reveal complex deglutition disorders and to aid precise planning of individualized functional swallowing therapy.
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Relatively little investigation has been conducted to determine whether patients who have been on long-term mechanical ventilation suffer from a specific type of aspiration or other swallowing abnormalities. Thus, the objectives of this videofluoroscopy study were to evaluate whether pathognomonic types or patterns of deglutition disorders exist in patients who were mechanically ventilated for a prolonged period of time.
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All examinations were carried out by one of three experienced radiologists using a fluoroscopy unit (Pantoscop 3 or 5; Siemens, Erlangen, Germany) and were recorded on videotapes (BVW 75 Betacam SP; Sony, Tokyo, Japan).
The videofluoroscopic study was performed with the patient in the upright position in the lateral and anteroposterior projections. The first series consisted of 3 ml, 5 ml, 10 ml, and 15 ml of water-soluble, low-osmolar (0.616 osm/kg water), iodinated (300 mg/ml) contrast material (iopamidol) (Gastromiro; Gerot, Vienna, Austria). Aspiration was defined as the entrance of contrast material into the airway below the level of the glottis. In cases of aspiration, patients received 3 or 5 ml of high-density (250% g/v) barium sulfate (Prontobario; E-Z-EM, New York, NY), depending on the severity of aspiration in the previous series. If aspiration occurred again, the examination was terminated. Otherwise, patients received up to 15 ml of high-density barium. In patients without evidence of aspiration during the series with water-soluble contrast, an additional series with high-density barium (increasing amounts of contrast up to 15 ml) was performed.
Swallowing can be physiologically divided into oral, pharyngeal, and esophageal stages. The oral stage is voluntary and includes ingestion, processing and containment, transfer of the bolus onto the back of the tongue, and initiation of transportation. The pharyngeal stage is automatic and includes oral and pharyngeal propulsion, velopharyngeal closure, hyoid bone movement, laryngeal elevation, closure of the airways, pharyngeal constrictor activity, and the pharyngoesophageal segment. The esophageal stage consists of bolus transportation through the thoracic esophagus.
The patients were analyzed for functional abnormalities of the tongue (leaking of contrast material into the pharynx before initiation of swallowing, abnormal loading of contrast material onto the tongue, paresis, and motility disorders); soft palate (leaking of contrast material to the nasal cavity in the case of insufficient elevation to prevent nasal regurgitation); epiglottis (incomplete tilting); hyoid and larynx (penetration or aspiration of contrast material into the trachea); pharynx (delayed triggering of reflex or paresis); and the upper esophageal sphincter (insufficient or delayed opening, stenosis) [10]. We determined the type of aspiration, predeglutitive (before swallowing), intradeglutitive (during swallowing), and postdeglutitive (after swallowing); the occurrence of combinations thereof; and the frequency of other swallowing abnormalities. The results were retrospectively evaluated. A chi-square test for equal proportions was used to assess associations between variables under study. A p value of 0.05 or less was considered significant.
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The use of low-osmolar, nonionic, water-soluble contrast material in patients with clinical symptoms of aspiration has been proven to cause no deleterious effects to the lung parenchyma, unlike water-soluble hyperosmolar contrast material [13,14]. If contrast materials with different viscosities are administered, the examination yields additional clinical information concerning the possibility of oral alimentation with different food consistencies.
The reason for the different types and combinations of aspiration and other swallowing disorders has been discussed frequently in the literature with multiple causes postulated. There are, however, two main theories that suggest a mechanical or a neurologic impairment of swallowing functions. "Anchoring" of the larynx to the neck and mechanical irritation of the larynx by a tracheostomy tube or endotracheal intubation have been suggested as possible causes [15,16]. However, swallowing dysfunctions may persist despite removal of the tracheostomy tube, which makes an additional neurologic dysfunction probable (e.g., oromotor dysfunctions as a results of weakness or inactivity, impaired sensation, and motor nerve dysfunction) [15, 16]. DeVita and Spierer-Rundback [16] reported that prolonged intubation with or without a tracheostomy may cause prolonged and severe swallowing dysfunction, which corresponds to our data.
No association between the level of consciousness and aspiration was detected [6]. Long-term intensive care unit patients frequently develop a "critically ill polyneuropathy" that may result in discoordination of the swallow response [17]. Earlier studies showed that in these patients, more than one type of swallowing dysfunction is commonly present [15, 16]. Frequent findings were vallecular stasis, piriform sinus stasis, abnormal laryngeal elevation, and tracheal aspiration. However, a study by Tolep et al. [15] revealed no statistically significant difference in swallowing dysfunction in patients after prolonged ventilation with or without a neurologic deficit. Therefore, neurologic deficit was not a variable in our study.
To our knowledge, the different combinations of pre-, intra-, and postdeglutitive aspiration and associated dysfunctions have not been assessed. Nevertheless, there could be a trend toward specific findings in swallowing disorders, particularly with respect to the type of aspiration, in this highly selected group of patients. Like previous studies, our investigations revealed a large variety of different swallowing abnormalities. We could not discover a typical pattern of swallowing dysfunctions in our patients. Neither the type of aspiration nor the associated dysfunctions were shown to be pathognomonic. One drawback of our study was the small sample size, which made statistical evaluation of significance difficult. The rather low number of symptomatic patients who were admitted to our institution for a videofluoroscopic study is most likely because patients are frequently transferred to rehabilitation facilities after discharge from the intensive care or intermediate care unit.
Another limitation is the relatively high age of patients in our group (mean age, 66 years). Ekberg and Feinberg [18] found altered swallowing function in up to 84% of elderly patients without dysphagia. In their study, oral sensorimotor incoordination was detected in 63% of the patients. Pharyngeal dysfunction was seen in 25% and pharyngoesophageal segment abnormalities occurred in 39% of the patients. The authors reported an occurrence of minor aspiration (misdirected swallowing) in 20% of their patients and concluded that major aspiration is likely to be a result of disease and not to be a result of normal aging. These data correspond with our findings, with abnormalities in our patients shown on imaging including dysfunctions of the oral cavity (48%), soft palate (10%), and the upper esophageal sphincter (24%). Despite these most likely age-related findings we found a much higher frequency of aspiration (86% versus 20%). In our opinion, the reason for the large variety of combinations of swallowing disorders is the large spectrum of underlying diseases in our group of patients.
Those patients who received follow-up videofluoroscopic examinations after functional swallowing training showed an improvement in swallowing. Functional swallowing therapy comprises causal and compensatory treatment techniques [19]. Causal treatment techniques aim to improve impaired functions (e.g., ice stimulation of the swallowing reflex or exercises to improve glottic closure). Compensatory treatment techniques compensate for the impaired swallowing function. These techniques consist of changes in posture (e.g., chin-down position in patients leaking with predeglutitive aspiration, head rotation in patients with pharyngeal pooling and postdeglutitive aspiration); swallowing maneuvers (e.g., supraglottic swallow or Mendelsohn maneuver [prolonged elevation of hyoid and larynx, which improves the opening of the pharyngoesophageal segment]); or dietary modifications. The type of aspiration and the components of swallowing pathophysiology determine the therapy regimen.
The small subset of patients with follow-up examinations and the large time interval between extubation and the follow-up examination make it difficult to draw conclusions. Evaluation of swallowing therapy was not part of the study; however, some patients revealed, even in their initial videofluoroscopic study, a prompt response to the individually tailored therapy.
We conclude that patients who are symptomatic after long-term intubation do not develop a specific type or pattern of swallowing dysfunction or aspiration but, instead, have a large variety of aspiration types and associated swallowing disorders. Nevertheless, videofluoroscopy contributes, with its ability to investigate and document complex deglutition disorders, to precise individualized planning of functional swallowing therapy.
Acknowledgments
We thank Mary McAllister and Thomas Helbich for the review of this article.
Special thanks also to Barbara Schneider for the statistical workup.
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