Special Lectures

Human Security Special Lecture B

Date : Tuesday 21st February, 2017
Time : 17:00 – 19.00
Venue: School of Medicine Building 6, 1F Conference Room #1(Seiryo Campus).
Topic: Dysphagia Rehabilitation.
Lecturer : Professor Shin-ichi Izumi M.D., Ph.D. (Department of Physical Medicine & Rehabilitation, Dean of Tohoku University Graduate School of Biomedical Engineering).
Lecture Number: eight (final lecture)

Professor Izumi started by defining dysphasia as difficulty or discomfort in swallowing. There are some foods which are good for swallowing and others that are bad for swallowing especially in the elderly people. With respect to the above topic, professor Izumi focused his lecture on safe swallowing. He said soft foods are safe for swallowing. However, mochi which is a soft type of food is bad for swallowing due to the fact that it is sticky. Foods like jelly, blended foods are good for swallowing. Videofluoroscopy and videoendoscopy are used to look at the way swallowing works. They are used to investigate problems associated with swallowing and also give a clearer picture of what is happening in the mouth or throat when swallowing.

Professor Izumi said swallowing is a very dynamic movement, therefore if the muscles of the throat become weak it will be difficult to swallow. The centre for swallowing is in the Medulla Oblongata. Swallowing involves both reflex and voluntary movement. The oral phase of swallowing is voluntary whilst the pharyngeal and oesophageal phases are reflex. Dysphagia causes medical problems such as choking, malnutrition and pneumonia (due to aspiration of fluid or saliva into the airway).

The clinical examination of dysphagic patients involves repetitive saliva swallowing test (RSST), modified water swallowing test (MWST), videofluoroscopic examination (VF) and videoendoscopic examination (VE). Normal RSST is 4 swallows in 30 seconds and that of MWST is 5. Professor Izumi mentioned that during rehabilitation saliva swallowing training alone is not enough, food swallowing training should also be carried out.

Professor Izumi further explained that rehabilitative treatment involves posture, food texture and risk management. Rotating the neck to the right will lead to closure of the right oesophagus and opening of the left oesophagus thus reducing pharyngeal pooling. Chin protrusion opens the oesophageal inlet and pinching the nostril shut reduces swallowing pressure thus allowing more fluids into the oesophagus. Also, reclining reduces aspiration of food. Water is not used during rehabilitative treatment because it can be easily aspirated; jelly is rather used.

Six case scenarios were discussed by professor Izumi:

The first case discussed by Professor Izumi was a 73 y/o patient who had oesophageal cancer. After surgery he could eat orally without choking but suffered from pneumonia. Physical examination showed that he had clear consciousness, wet hoarseness, RSST: 4 swallows/30sec (normal), MWST: grade 5 (normal). VF revealed severe silent aspiration after eating regular food at 90 degree upright position. Therefore tube feeding was carried out on this patient. After one month of treatment with the patient at 45 deg reclining and head tilted forward VF revealed while eating jelly, laryngeal penetration and pharyngeal pooling. When food was eaten through the left side and the neck rotated towards the right, pharyngeal pooling was reduced. Final VF at 90 deg upright position with neck rotated towards the right when eating regular food revealed no aspiration and laryngeal penetration occurred on neck at neutral position. Professor Izumi revealed that oral care might prevent pneumonia in this patient.

Case two was about a 50 y/o patient with Wallenberg syndrome who had been experiencing infarction at the left lateral area of the medulla oblongata for 4 months. Upon physical examination he had left side ataxia (lack of voluntary coordination of muscle movements ), sensory impairment of the face and right upper/lower extremities, hoarseness, RSST 0 swallow/30 sec and MWST 1 (unable to swallow). Initial VF when at 45 deg reclining position and eating soft food revealed reduced elevation of soft palate, severely impaired laryngeal elevation and no relaxation of cricopharyngeus muscle (no opening of esophagus inlet). This patient needed surgery that involved laryngeal elevation and cricopharyngeal myotomy. After surgery with patient at 30 deg recline posture, VF revealed no aspiration, food was transported to the esophagus and nasal cavity closure was impaired. Reduction of swallowing pressure was suggested. Final VF revealed reduced edema, laryngeal penetration and pooling on the residue of the cricopharyngeal muscle. However the patient was able to cough out the aspirated food.

The third case was about a 58y/o patient also with Wallenberg syndrome who suffered from dysphagia for 8 months due to right giant aneurysm of the vertebral artery, which was treated by embolization. Physical findings showed consciousness alert, left ataxic hemiparesis, sensory impairment of right-side face and left upper/lower extremities, dysarthria, RSST 2 swallows/30sec and MWST 3 (wet hoarseness). VE revealed good vocal cord closure, saliva pooling with laryngeal penetration and no cough reflex. Initial VF at 60 deg reclining with head tilted forward and jelly eaten revealed reduced laryngeal elevation, delayed swallowing reflex and aspiration without coughing (severe silent aspiration). This patient didn’t eat orally, intermittent oroesophageal (IOE) tube feeding was done. VF at discharge from the hospital with 60 deg reclining and head tilted forward revealed silent aspiration of fluid. However jelly bolus can be swallowed without aspiration. Follow up VF with 30 deg reclining and head tilted forward revealed almost no aspiration except for food mixed with liquid or food collapsing easily in pieces. Follow up VF2 with 30 deg reclining and regular food revealed a small amount of pooling and mild laryngeal penetration with fluid without aspiration. Aspiration of fluid at upright position was reduced by thickening liquid therefore he was fed jelly.

Fourthly professor Izumi spoke about a 73y/o patient with cerebral infarction who in October, 2004, had right hemiplegia and aphasia followed by recurrent aspiration pneumonia. In January, 2005, gastrostomy was done. Physical findings showed alert consciousness, severe right hemiplegia and aphasia, oro-buccal apraxia, dysphagia, RSST unable to be tested due to aphasia and MWST 4. Initial VF at 30 deg recline posture and eating soft food revealed impaired food transport due to apraxia, good reflex and mild pooling which was cleared by repetitive swallowing. Second VF with upright posture and soft food revealed improved food transport. Reattack of the cerebral infarction on the right hemisphere was carried out but there was deteriorated dysphagia due to bilateral hemispheric damage. After re-attack, when jelly was eaten at 45 deg reclined posture, VF revealed worsening of food transport, good initial swallowing and repetitive swallow induced laryngeal penetration or aspiration. This patient had gastrostomy and fed on one or two bites of jelly at a time.

The fifth patient was 51y/o with lung cancer and he did chemotherapy and radiation therapy in 8/1983. In 5/1984 he did tongue base resection and chemotherapy. Also in 5/2004 he experienced dysphagia and recurrence of tongue cancer, he then had tongue hemi-resection (left side) and reconstruction, chemotherapy and radiation therapy. Furthermore in 12/2004 he experienced a recurrence and had a wide resection of the epiglottis with no choking when eating blended food. In 5/2005 he had dysphagia due to upper respiratory inflammation and finally in 7/2005 he had gastrostomy. Physical findings showed RSST: no swallow/30secs and MWST1: no swallow with choking.

VE revealed left side tongue defect to just above the epiglottis, saliva pooling in the pharynx, impaired glottal closure, cough reflex was reserved and no swallowing reflex. VF revealed at 45deg with thick fluid impaired nasal cavity closure due to reduced soft palate elevation, impaired esophageal inlet opening due to reduced laryngeal elevation, food transport impairment due to tongue defect, no aspiration and no swallowing. Chin protrusion was done in order to increase swallowing pressure. During chin protrusion VF revealed that a small amount of liquid passed through the esophageal inlet through a great amount of the patient’s effort. The nostril was pinched shut to help increase esophageal inlet opening. During this process, VF revealed increased amount of liquid passing through the esophagus. Therefore oral feeding commenced.

The sixth case was a 48y/o patient with clival meningioma (brain tumor) who after resection of clival meningioma followed by gastrostomy and tracheostomy experienced dysphagia. Physical findings showed alert consciousness, impaired eye movement, severe dysarthria, severe dysphagia, and ataxia. Before surgery, VE revealed severe saliva pooling and penetration and VF
revealed impaired liquid retention in the mouth, delayed reflex and aspiration with choking. This patient could not eat orally, had recurrent pneumonia and severe dysarthria. An informed consent was needed from the patient before the surgery was done because he will lose his speech after the operation but will eat orally with no aspiration pneumonia.

Professor Izumi emphasized that dysphagia and respiratory disturbances also occur as a result of severe medical conditions.

The final case dealt by professor Izumi was a 65y/o patient with severe pneumonia who after two weeks of cough symptom developed acute respiratory distress syndrome and the cause was not identified. Physical findings showed tracheostomy, dysphagia and that breathing and swallowing needed much effort. VF revealed that before relaxation there is effortful swallowing which led to aspiration and there was no aspiration upon swallowing after relaxation. This revealed that the patient suffered dysphagia due to muscle contraction and must therefore be relaxed when eating.

In conclusion professor Izumi discussed the kinds of food that are needed in disaster areas. In disaster areas, shortage of water supply might occur. Food like bread, rice are not good for eating without water, hence they are not good for eating in disaster areas. On the other hand, jellies and liquids were recommended for eating in disaster areas.

Reported by:
Tracey Elizabeth Claire Jones
Division of International Cooperation for Disaster Medicine
Graduate School of Medicine