Hypopharyngeal Diverticulum: Toward a Unified Understanding of Its Etiopathogenesis Abstract The etiopathogenesis of Zenker’s diverticulum (ZD) remains uncertain. Increased hypopharyngeal pressure due to a hypertonic upper esophageal sphincter results in herniation proximal to the sphincter producing a pulsion diverticulum. Gastroesophageal reflux, which is known to induce shortening of the injured esophagus, likely plays a prominent role in ZD formation by pulling the cricopharyngeus muscle (CPM) away from the anchored inferior constrictor muscle. This creates a “weak zone” encouraging herniation. A bilobed diverticulum may originate from continuation of the fibrous midline raphe inferiorly to developmentally include part of the CPM. We report using laser endoscopy to divide the inter-diverticular septum followed by transmucosal cricopharyngeus myotomy. Presentation of a rare, bilobed diverticulum emphasizes the importance of the midline prevertebral raphe in anchoring the pharyngeal constrictor muscles with respect to the CPM. This lends support to the hypothesis that the etiopathogenesis of ZD is multifactorial while guiding us to a unified understanding of ZD.

Comment on “Sarcopenia is an Independent Risk Factor for Dysphagia in Community-Dwelling Older Adults”

Fluid Testing Methods Recommended by IDDSI

Disruption of the Obligatory Swallowing Sequence in Patients with Wallenberg Syndrome Abstract Although the sequence of events involved in swallowing varies among healthy adults, healthy adults demonstrate some consistent patterns, including opening of the upper esophageal sphincter (UES) prior to maximum laryngeal elevation (LE). Previous animal studies suggested that swallowing is regulated by a neuronal network in the medulla, and lateral medullary infarction, or Wallenberg syndrome, frequently causes dysphagia. This retrospective, observational, multicenter study aimed to determine if the sequence of swallowing events was disturbed in patients with Wallenberg syndrome compared with previously published reference data for healthy adults. The study subjects included 35 patients with Wallenberg syndrome admitted to three hospitals in Japan from 1/4/2009 to 31/3/2017. Sixteen timing events, including maximum LE and UES opening, and the intervals between events were measured. If the sequence of events was the same as in healthy adults, the interval value was positive, and if the sequence of events was opposite to that in healthy adults, the value was negative. The median interval from UES opening to maximum LE was − 0.02 s (range − 0.80 to 0.89, 95% CI − 0.14 to 0.10). About half of the Wallenberg cases showed negative values indicating that the sequence was reversed. These results suggest that lateral medullary infarction impairs the sequence of swallowing events.

Sarcopenia is an Independent Risk Factor for Dysphagia in Community-Dwelling Older Adults Abstract Dysphagia is common in older adults and associated with increased socioeconomic burdens. Recently, sarcopenia is considered to be a possible contributor for dysphagia. The purpose of this study is to investigate the association of dysphagia with sarcopenia in a geriatric population in Korea. This is a cross-sectional study using data from the Korean Longitudinal Study on Health and Aging (KLoSHA). Community-dwelling men and women aged 65 years and older without common causes of dysphagia in Seongnam City, Korea were included (N = 236). Dysphagia was screened using Standardized Swallowing Assessment. Appendicular skeletal muscle mass was calculated by dual-energy X-ray absorptiometry. Grip strength and long-distance corridor walk were assessed. Of 236 subjects, 54 (22.9%) showed dysphagia and 38 (16.1%) showed sarcopenia. Fourteen (5.9%) participants were diagnosed with sarcopenic dysphagia. In multiple logistic regression analysis for dysphagia, sarcopenia was the only significant variable with odds ratio of 2.738 (95% confidence interval 1.160–6.466). Sarcopenia was associated with increased risk of dysphagia in community-dwelling older adults having no common causes of dysphagia even after adjusting for possible confounders. A prospective study with a larger sample size is needed to reveal their causal relationship in the future.

A Device that Models Human Swallowing Abstract The pharynx is critical for correct swallowing, facilitating the transport of both air and food transport in a highly coordinated manner, and aberrant co-ordination causes swallowing disorders (dysphagia). In this work, an in vitro model of swallowing was designed to investigate the role of rheology in swallowing and for use as a pre-clinical tool for simulation of different routes to dysphagia. The model is based on the geometry of the human pharynx. Manometry is used for pressure measurements and ultrasonic analysis is performed to analyze the flow profiles and determine shear rate in the bolus, the latter being vital information largely missing in literature. In the fully automated model, bolus injection, epiglottis/nasopharynx movement, and ultrasound transducer positioning can be controlled. Simulation of closing of the airways and nasal cavity is modulated by the software, as is a clamping valve that simulates the upper esophageal sphincter. The actions can be timed and valves opened to different degrees, resembling pathologic swallowing conditions. To validate measurements of the velocity profile and manometry, continuous and bolus flow was performed. The respective velocity profiles demonstrated the accuracy and validity of the flow characterization necessary for determining bolus flow. A maximum bolus shear rate of 80 s−1 was noted for syrup-consistency fluids. Similarly, the manometry data acquired compared very well with clinical studies.

Laryngeal Vibration Increases Spontaneous Swallowing Rates in Chronic Oropharyngeal Dysphagia: A Proof-of-Principle Pilot Study Abstract Previously, vibratory stimulation increased spontaneous swallowing rates in healthy volunteers indicating that sensory stimulation excited the neural control of swallowing. Here, we studied patients with severe chronic dysphagia following brain injury or radiation for head and neck cancer to determine if sensory stimulation could excite an impaired swallowing system. We examined (1) if laryngeal vibratory stimulation increased spontaneous swallowing rates over sham (no stimulation); (2) the optimal rate of vibration, device contact pressure, and vibratory mode for increasing swallowing rates; and (3) if vibration altered participants’ urge to swallow, neck comfort, and swallow initiation latency. Vibration was applied to the skin overlying the thyroid lamina bilaterally in thirteen participants to compare vibratory rates 30, 70, 110, 150, or 70 + 110 Hz, different devices to neck pressures (2, 4, or 6 kilopascals), and pulsed versus continuous vibration. Swallows were confirmed from recordings of laryngeal accelerometry and respiratory apneas and viewing neck movement. Participants’ swallowing rates, urge to swallow, discomfort levels, and swallow initiation latencies were measured. Vibration at 70 Hz and at 110 Hz significantly increased swallowing rates over sham. All vibratory frequencies except 70 + 100 Hz increased participants’ urge to swallow, while no pressures or modes were optimal for increasing urge to swallow. No conditions increased discomfort. Vibration did not reduce measures of swallow initiation latency using accelerometry. In conclusion, as non-invasive neck vibration overlying the larynx increased swallowing rates and the urge to swallow without discomfort in patients with chronic dysphagia, the potential for vibratory stimulation facilitating swallowing during dysphagia rehabilitation should be investigated.

Economic Analysis of a Three-Arm RCT Exploring the Delivery of Intensive, Prophylactic Swallowing Therapy to Patients with Head and Neck Cancer During (Chemo)Radiotherapy Abstract Research advocates for the use of intensive, prophylactic swallowing therapy to help reduce the severity of dysphagia in patients receiving (chemo)radiotherapy ([C]RT) for head/neck cancer (HNC). Unfortunately, the intensity of this therapy, coupled with growing patient numbers and limited clinical resources, provides challenges to many international cancer facilities. Telepractice has been proposed as a potential method to provide patients with greater support in home-practice, whilst minimising burden to the health service. This study investigated the clinical and patient-attributable costs of delivering an intensive, prophylactic swallowing therapy protocol via a new telepractice application “SwallowIT” as compared to clinician-directed FTF therapy and independent patient self-directed therapy. Patients (n = 79) with oropharyngeal HNC receiving definitive (C)RT were randomised to receive therapy via a: clinician-directed (n = 26), patient-directed (n = 27), or SwallowIT-assisted (n = 26) model of care. Data pertaining to health service costs (service time, consumables, therapy resources), patient-attributable costs (travel and wages) and patient-reported health-related quality of life (QoL) (AQoL-6D) were collected. SwallowIT provided a cost-efficient model of care when compared to the clinician-directed model, with significant cost savings to both the health service and to HNC consumers (total saving of $1901.10 AUD per patient; p < 0.001). The SwallowIT model also proved more cost-effective than the patient-directed model, yielding clinically significantly superior QoL at the end of (C)RT, for comparable costs. Overall, when compared to the alternate methods of service-delivery, SwallowIT provided a financially viable and cost-effective method for the delivery of intensive, prophylactic swallowing therapy to patients with HNC during (C)RT.

Understanding Dysphagia Care in the Community Setting Abstract Factors including health policy reform and the aging population are increasing demand for quality healthcare in the community. People with dysphagia are supported by speech-language pathologists (SLPs) in hospital and community settings; however, little is known about the nature of dysphagia services offered by SLPs in the community. The aim of this study was to investigate SLP services and practices provided to community-based adults with dysphagia. A national cohort (n = 144) of SLPs working with community-based clients with dysphagia completed an online survey. Results revealed that clients with neurological conditions comprised the largest proportion of the caseload. Primary referral sources were family doctors (42.4%) or other health professionals (37.5%), with low rates of self-referral. Services were primarily delivered via individual sessions (84.1%), usually within the client’s home (80% saw clients at home). While many clinicians were using both clinical and instrumental assessments, half had to refer clients to the other services to access instrumental assessment. Most provided assessment and rehabilitation services, though a few (28.5%) reported using formal outcome or quality-of-life measures. Only 43.8% referred or encouraged clients or caregivers to access support or social groups and a few SLPs incorporated social participation or client well-being aspects in treatment. Speech-language pathology (SLP) practices in the community appear similar to what occurs in the acute setting, which are inherently biomedical. This may not be optimal care for clients with dysphagia who live at home and their caregivers. Further exploration about what clients and caregivers want from community-based SLP services is warranted.

Development of a Non-invasive Device for Swallow Screening in Patients at Risk of Oropharyngeal Dysphagia: Results from a Prospective Exploratory Study Abstract Oropharyngeal dysphagia is prevalent in several at-risk populations, including post-stroke patients, patients in intensive care and the elderly. Dysphagia contributes to longer hospital stays and poor outcomes, including pneumonia. Early identification of dysphagia is recommended as part of the evaluation of at-risk patients, but available bedside screening tools perform inconsistently. In this study, we developed algorithms to detect swallowing impairment using a novel accelerometer-based dysphagia detection system (DDS). A sample of 344 individuals was enrolled across seven sites in the United States. Dual-axis accelerometry signals were collected prospectively with simultaneous videofluoroscopy (VFSS) during swallows of liquid barium stimuli in thin, mildly, moderately and extremely thick consistencies. Signal processing classifiers were trained using linear discriminant analysis and 10,000 random training–test data splits. The primary objective was to develop an algorithm to detect impaired swallowing safety with thin liquids with an area under receiver operating characteristic curve (AUC) > 80% compared to the VFSS reference standard. Impaired swallowing safety was identified in 7.2% of the thin liquid boluses collected. At least one unsafe thin liquid bolus was found in 19.7% of participants, but participants did not exhibit impaired safety consistently. The DDS classifier algorithms identified participants with impaired thin liquid swallowing safety with a mean AUC of 81.5%, (sensitivity 90.4%, specificity 60.0%). Thicker consistencies were effective for reducing the frequency of penetration–aspiration. This DDS reached targeted performance goals in detecting impaired swallowing safety with thin liquids. Simultaneous measures by DDS and VFSS, as performed here, will be used for future validation studies.