Gender Effect on Oral Volume Capacity

Studies have shown anatomical and functional differences between men and women with respect to the mouth, pharynx, upper esophageal sphincter, and esophagus. The aim of this investigation was to analyze the influence of gender, body mass index (BMI), age, and orofacial anthropometric measurements on the intraoral maximum volume capacity for liquid. The investigation included asymptomatic subjects, 56 females and 44 males, aged 19-53 years. The volunteers sucked water through a straw up to the maximum tolerated oral volume, which was greater in men (71.2 +/- A 15.0 ml) than in women (55.4 +/- A 13.4 ml). Age, BMI, height, and number of teeth had no influence on the intraoral tolerated volume. Anthropometric orofacial measurements were greater in men than in women. In individuals with height between 1.66 and 1.89 m, anthropometric orofacial measurements were greater in men than in women, and the tolerated intraoral volume was greater in men than in women. There was a positive correlation between orofacial measurements and intraoral maximum volume. In conclusion, men have the capacity to place a larger volume of water inside their mouth than women. This observation is associated with higher anthropometric orofacial measures, but not with age, number of teeth, height, or BMI.

Primary malignant melanoma of the esophagus: a rare and aggressive disease

Primary malignant melanoma of the esophagus is an uncommon tumor, with approximately 300 cases having been reported thus far. The purpose of this study was to describe a case of a 60 year-old man with a 10 month history of progressive dysphagia and thoracic pain, the investigations of which led to a diagnosis of primary malignant melanoma of the esophagus. The patient underwent a transhiatal esophagectomy with subcarinal lymphadenectomy, and isoperistaltic gastric tube replacement of the esophagus. Nine months after surgery, he developed ischemic colitis, and metastasis in the mesentery was diagnosed. His disease progressed and he died one year after the esophagectomy. A review of the literature was performed.

Risk factors for swallowing dysfunction in stroke patients

CONTEXT: Stroke is a frequent cause of dysphagia. OBJECTIVE: To evaluate in a tertiary care hospital the prevalence of swallowing dysfunction in stroke patients, to analyze factors associated with the dysfunction and to relate swallowing dysfunction to mortality 3 months after the stroke. METHODS: Clinical evaluation of deglutition was performed in 212 consecutive patients with a medical and radiologic diagnosis of stroke. The occurrence of death was determined 3 months after the stroke. RESULTS: It was observed that 63% of the patients had swallowing dysfunction. The variables gender and specific location of the lesion were not associated with the presence or absence of swallowing dysfunction. The patients with swallowing dysfunction had more frequently a previous stroke, had a stroke in the left hemisphere, motor and/or sensitivity alterations, difficulty in oral comprehension, alteration of oral expression, alteration of the level of consciousness, complications such as fever and pneumonia, high indexes on the Rankin scale, and low indexes on the Barthel scale. These patients had a higher mortality rate. CONCLUSIONS: Swallowing evaluation should be done in all patients with stroke, since swallowing dysfunction is associated with complications and an increased risk of death.

Esophageal contractions, bolus transit and perception of transit after swallows of liquid and solid boluses in normal subjects

CONTEXT: Esophageal dysphagia is the sensation that the ingested material has a slow transit or blockage in its normal passage to the stomach. It is not always associated with motility or transit alterations. OBJECTIVES: To evaluate in normal volunteers the possibility of perception of bolus transit through the esophagus after swallows of liquid and solid boluses, the differences in esophageal contraction and transit with these boluses, and the association of transit perception with alteration of esophageal contraction and/or transit. METHODS: The investigation included 11 asymptomatic volunteers, 4 men and 7 women aged 19-58 years. The subjects were evaluated in the sitting position. They performed swallows of the same volume of liquid (isotonic drink) and solid (macaroni) boluses in a random order and in duplicate. After each swallow they were asked about the sensation of bolus passage through the esophagus. Contractions and transit were evaluated simultaneously by solid state manometry and impedance. RESULTS: Perception of bolus transit occurred only with the solid bolus. The amplitude and area under the curve of contractions were higher with swallows of the solid bolus than with swallows of the liquid bolus. The difference was more evident in swallows with no perception of transit (n = 12) than in swallows with perception (n = 10). The total bolus transit time was longer for the solid bolus than for the liquid bolus only with swallows followed by no perception of transit. CONCLUSION: The results suggest that the perception of esophageal transit may be the consequence of inadequate adaptation of esophageal transit and contraction to the characteristics of the swallowed bolus.

Revisão analítica das escalas de disfagia

INTRODUÇÃO: Instrumento eficiente para medição da disfagia, facilmente reprodutível e estatisticamente consistente, deveria fornecer dados mais consistentes sobre os resultados e acompanhamento de doenças com disfagia. As propostas existentes mostram ampla cobertura na avaliação do sintoma disfágico. OBJETIVOS: Analisar as escalas de disfagia disponíveis sugerindo as que permitem avaliação mais objetiva e estatisticamente consistente, e não apenas ferramenta de mensuração, e sugerir as que melhor quantificam o sintoma e úteis para seguimento dos pacientes. MÉTODO: Foram pesquisados os seguintes descritores no Pubmed: "disfagia", "escala", "index", "score". Dez artigos foram selecionados entre 1995 e 2012 com propostas de escalas para a disfagia. RESULTADOS: A maioria das escalas não atingiram os requisitos para serem classificadas como ferramenta completa na avaliação de qualquer disfagia. Muitas são específicas para uma única doença, e poucas com maior abrangência, não têm consistência estatística. Para disfagia orofaríngea (cervical), as escalas FOIS e ASHA são citadas com mais frequência. Na disfagia motora (cervical), a de Zaninotto e Youssef têm aplicabilidade prática, mas ambas necessitam de validação estatística. A de Zaninotto parece ser mais precisa por incluir mais variáveis (disfagia, dor no peito e azia). As escalas que cobrem as duas formas de disfagia (ASHA e DHI) são bem diferentes em seus objetivos. A DHI é escala publicada recentemente examina os dois tipos de disfagia e tem validação estatística bem estruturada. Importante passo no futuro seria testar essa nova proposta com amostra mais expressiva e representativa, provavelmente consagrando esse novo instrumento de avaliação. CONCLUSÃO: As escalas mais frequentes de disfagia relatadas nos últimos 17 anos têm propósito e estruturas diferentes. As escalas FOIS e ASHA são muitas vezes utilizadas para a avaliação da disfagia orofaringeana (região cervical), ambas focadas em terapia nutricional. Para a avaliação motora baixa, a escala de Zaninotto e Youssef tem aplicação prática, e a DHI parece representar a ferramenta mais promissora na avaliação global da disfagia.

Estudo multicêntrico sobre escalas para grau de comprometimento em disfagia orofaríngea neurogênica

OBJETIVO: Analisar a concordância entre distintas escalas para grau de comprometimento em disfagia orofaríngea neurogênica. MÉTODOS: Foi realizado estudo clínico transversal. Participaram 200 indivíduos com disfagia orofaríngea neurogênica, 108 do gênero masculino e 92 do gênero feminino, com idades de 3 meses a 91 anos. Foram aplicadas quatro escalas para classificar o grau de comprometimento da disfagia orofaríngea, sendo duas escalas clínicas e duas videofluoroscópicas. Análises estatísticas foram realizadas para verificar a concordância entre as escalas clínicas e objetivas. RESULTADOS: Os resultados mostraram concordância muito boa entre as escalas clínicas estudadas (Kappa=0,92) e concordância moderada entre as escalas objetivas (Kappa=0,52). CONCLUSÃO: Embora a concordância entre as escalas clínicas tenha sido muito boa e entre as escalas objetivas tenha sido moderada, ainda é necessária ampla discussão e possível revisão dos parâmetros que definem o grau de comprometimento da disfagia orofaríngea em pacientes neurológicos.

Clinical diagnosis of hyposalivation in hospitalized patients

OBJECTIVE: The aim of this study was to evaluate the effectiveness of clinical criteria for the diagnosis of hyposalivation in hospitalized patients. MATERIAL AND METHODS: A clinical study was carried out on 145 subjects (48 males; 97 females; aged 20 to 90 years). Each subject was clinically examined, in the morning and in the afternoon, along 1 day. A focused anamnesis allowed identifying symptoms of hyposalivation, like xerostomia complaints (considered as a reference symptom), chewing difficulty, dysphagia and increased frequency of liquid intake. Afterwards, dryness of the mucosa of the cheecks and floor of the mouth, as well as salivary secretion during parotid gland stimulation were assessed during oral examination. RESULTS: Results obtained with Chi-square tests showed that 71 patients (48.9%) presented xerostomia complaints, with a significant correlation with all hyposalivation symptoms (p <0.05). Furthermore, xerostomia was also significantly correlated with all data obtained during oral examination in both periods of evaluation (p<0.05). CONCLUSION: Clinical diagnosis of hyposalivation in hospitalized patients is feasible and can provide an immediate and appropriate therapy avoiding further problems and improving their quality of life.

Niemann-Pick disease type C symptomatology: an expert-based clinical description

Niemann-Pick disease type C (NP-C) is a rare, progressive, irreversible disease leading to disabling neurological manifestations and premature death. The estimated disease incidence is 1:120,000 live births, but this likely represents an underestimate, as the disease may be under-diagnosed due to its highly heterogeneous presentation. NP-C is characterised by visceral, neurological and psychiatric manifestations that are not specific to the disease and that can be found in other conditions. The aim of this review is to provide non-specialists with an expert-based, detailed description of NP-C signs and symptoms, including how they present in patients and how they can be assessed. Early disease detection should rely on seeking a combination of signs and symptoms, rather than isolated findings. Examples of combinations which are strongly suggestive of NP-C include: splenomegaly and vertical supranuclear gaze palsy (VSGP); splenomegaly and clumsiness; splenomegaly and schizophrenia-like psychosis; psychotic symptoms and cognitive decline; and ataxia with dystonia, dysarthria/dysphagia and cognitive decline. VSGP is a hallmark of NP-C and becomes highly specific of the disease when it occurs in combination with other manifestations (e.g. splenomegaly, ataxia). In young infants (<2 years), abnormal saccades may first manifest as slowing and shortening of upward saccades, long before gaze palsy onset. While visceral manifestations tend to predominate during the perinatal and infantile period (2 months–6 years of age), neurological and psychiatric involvement is more prominent during the juvenile/adult period (>6 years of age). Psychosis in NP-C is atypical and variably responsive to treatment. Progressive cognitive decline, which always occurs in patients with NP-C, manifests as memory and executive impairment in juvenile/adult patients. Disease prognosis mainly correlates with the age at onset of the neurological signs, with early-onset forms progressing faster. Therefore, a detailed and descriptive picture of NP-C signs and symptoms may help improve disease detection and early diagnosis, so that therapy with miglustat (Zavesca®), the only available treatment approved to date, can be started as soon as neurological symptoms appear, in order to slow disease progression.

Einfluss der Aspiration auf die Zwei-Jahres-Mortalität von Patienten im prolongierten Weaning nach Dekanülierung

Diese Fall-Kontroll-Studie zeigt an einer Kohorte von 82 langzeitbeatmeten Patienten einer spezialisierten Weaningabteilung Aspiration bei 45 % der Patienten unmittelbar nach Entfernung der Trachealkanüle. Gesichert wurde die Aspiration durch schluckweises Trinken von mit Patentblau V gefärbten Wasser, das nach Durchtritt durch die Stimmlippen durch eine fiberoptische Untersuchung mit dem Bronchoskop durch das Tracheostoma mit dem Blick nach laryngeal nachzuweisen war. Diese Anzahl von 45 % stimmt gut mit den Daten aus der Literatur überein, die mit anderen Methoden zu ähnlichen Ergebnissen kommen. In dieser Arbeit gibt es keinen Vergleich gegen die fiberoptische Evaluation des Schluckens von nasal.rnIm Gegensatz zu anderen Arbeiten fanden wir keinen signifikanten Unterschied in der Länge der invasiven Beatmung, dem Alter oder der Komorbidität in beiden Gruppen. Während in anderen Arbeiten ein erhöhter CRP Wert ein Risikofaktor für eine erhöhte Mortalität war, konnten wir dies bei unseren Patienten nicht nachweisen.rnDurch insgesamt 21 Vergleiche von Alter, Geschlecht, Beatmungszeiten und klinischen Parametern konnte dargelegt werden, dass beide Gruppen mit und ohne Aspiration im Schluckversuch nahezu identisch sind. Es konnten keine statistisch signifikanten Unterschiede festgestellt werden. Somit basieren die Überlebensraten beider Patientengruppen auf dem Merkmal Aspiration.rnDiese Doktorarbeit zeigt als eine der ersten Veröffentlichungen, dass langzeitbeatmete Patienten mit Aspiration nach Dekanülierung innerhalb der ersten 200 Tage ein erhöhtes Mortalitätsrisiko haben im Vergleich zur Patientengruppe ohne Aspiration.rnIm weiteren Verlauf liefen die beiden Überlebenskurven beider Patientengruppen nach ca. 720 Tagen zusammen. In zukünftigen Untersuchungen sind bei einer höheren Fallzahl Komorbiditäten sowie Einzelmerkmale des Allgemeinzustandes der Patienten, wie Stärke der Atemmuskulatur, Hustenstoß, Somnolenz, Fähigkeit des Stimmbandschlusses zu berücksichtigen.rnDas stärkere Auseinanderklaffen der Kurven binnen der ersten 200 Tage führen wir am ehesten auf eine allgemeine Schwäche der Patienten mit Aspiration und vermindertem Hustenstoß bei verminderter Kraft der Atemmuskulatur zurück, wobei Somnolenz, Konzentrationsfähigkeit, Kooperationsfähigkeit und Stimmbandschluss auch eine wesentliche Rolle spielen könnten. Die CRP-Werte deuten nicht darauf hin, dass ein pneumonisches Geschehen einen direkten Einfluss auf die Überlebenskurven hat.rnDysphagie und Aspiration bei langzeitbeatmeten, tracheotomierten Patienten sind weiterhin ein zu wenig untersuchtes Gebiet. Es gibt bislang keine Leitlinien zur Diagnostik und Therapie dieser häufigen Komplikation, deren optimale Diagnose und Behandlung weiterhin unklar bleibt. Logopädische Begleitung der Patienten auf der Beatmungsstation scheint uns entscheidend. Das beste therapeutische Vorgehen bezüglich Kostaufbau und Vermeidung von Aspirationen ist weiterhin unbekannt.

Esophageal Dilation in Eosinophilic Esophagitis: Effectiveness, Safety, and Impact on the Underlying Inflammation

Esophageal dilation often leads to long-lasting relief of dysphagia in eosinophilic esophagitis (EoE). The aim of this study was to define the effectiveness, safety, and patient acceptance of esophageal dilation in EoE. In addition, we examined the influence of dilation on the underlying esophageal inflammation.

Type IV delayed-type hypersensitivity of the respiratory tract due to budesonide use: report of two cases and a literature review

Respiratory type-IV hypersensitivity reactions due to corticosteroids is a rare phenomenon. We describe two such cases. The first is a 37- year-old atopic woman who developed labial angioedema and nasal itching after the use of budesonide nasal spray. A month later, after the first puffs of a formoterol/budesonide spray prescribed for asthma, she noticed symptoms of tongue and oropharyngeal itching and redness with subsequent dysphagia, labial and tongue angioedema, and facial oedema. The second is a 15-year-old non-atopic woman who reported pruritic eruptions around the nostrils after using a budesonide nasal spray. A year later she presented with nasal pruritus with intense congestion and labial and facial oedema after using the same spray. Both patients were evaluated with patch-tests using the commercial T.R.U.E. test, a budesonide solution, and corticosteroid creams. Test evaluation was performed at 48 and 96 hours. In both patients, patch tests were positive to budesonide (++) on the second day. The first patient also had a positive (+) reaction to tixocortol-21-pivalate. All the other patch tests were negative. Clinicians should be aware that hypersensitivity reactions may occur during the use of nasal or inhaled corticosteroids.

Basilar artery occlusion

The clinical presentation of basilar artery occlusion (BAO) ranges from mild transient symptoms to devastating strokes with high fatality and morbidity. Often, non-specific prodromal symptoms such as vertigo or headaches are indicative of BAO, and are followed by the hallmarks of BAO, including decreased consciousness, quadriparesis, pupillary and oculomotor abnormalities, dysarthria, and dysphagia. When clinical findings suggest an acute brainstem disorder, BAO has to be confirmed or ruled out as a matter of urgency. If BAO is recognised early and confirmed with multimodal CT or MRI, intravenous thrombolysis or endovascular treatment can be undertaken. The goal of thrombolysis is to restore blood flow in the occluded artery and salvage brain tissue; however, the best treatment approach to improve clinical outcome still needs to be ascertained.

Severe esophageal injuries occurring after general anesthesia in two cats: case report and literature review

Two healthy cats underwent elective surgical procedures under general anesthesia. One developed severe esophagitis leading to esophageal rupture, mediastinitis, and pyothorax. The other cat developed esophageal stricture, diverticulum formation, and suspected iatrogenic perforation. Both cats had signs of dysphagia and regurgitation beginning a few days after anesthesia. The first cat also had severe dyspnea due to septic pleural effusion and pneumomediastinum. In the second cat, endoscopy revealed diffuse esophagitis, an esophageal stricture, and a large esophageal diverticulum. Rupture of the esophageal wall occurred while inflating the esophagus for inspection. Due to the poor prognosis, both cats were euthanized. Necropsy revealed severe esophageal changes. Postanesthetic esophagitis has been previously described in dogs and cats; however, severe life-threatening esophageal injuries rarely occur as a sequel to general anesthesia. To the authors' knowledge, esophageal rupture secondary to perianesthetic reflux has never been reported in cats.

Pediatric and adult eosinophilic esophagitis: similarities and differences

Early in the 1990s, several case series described adults suffering from dysphagia and children with refractory reflux symptoms, both accompanied by an eosinophil-predominant infiltration, thereby conclusively distinguishing it from gastroesophageal reflux disease. Eosinophilic esophagitis (EoE) was recognized as its own entity in the adult and in the pediatric literature. In the last decade, evidence has accumulated that EoE represents a T-helper (Th)2-type inflammatory disease. Remodeling of the esophagus is a hallmark of EoE, leading to esophageal dysfunction and bolus impaction. Familial occurrence and disease association with single-nucleotide polymorphisms underscore the influence of genetics in this disease. Eosinophilic esophagitis may affect individuals at any age, although the clinical presentation is highly age dependent. There is a significant allergic bias in the EoE population, with the majority of patients having concurrent allergic rhinitis, asthma, eczema, and/or a history of atopy. One noteworthy difference is that in children, EoE seems to be primarily a food antigen-driven disease, whereas in adults, mainly aeroallergen sensitization has been observed. Treatment modalities for EoE include the 3Ds: drugs, diet, and dilation. The crucial question of whether adult and pediatric EoE are different phenotypes of one single entity or whether we are confronted with two different diseases is still open. Here, we review similarities and differences between EoE in adults and children.

ESPEN Guidelines on Enteral Nutrition: Geriatrics

Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.