[Dysphagia] Response to Jonathan Bennett 1

[eripley at yahoo.com (Irene Campbell-Taylor)]

  Some weeks ago, I was asked a series of questions that I shall attempt to answer. First of all, as I have said many times, I am not expressing my ?viewpoint? or ?opinion? when I cite the best authorities on a topic. If it is a personal opinion, I say so.
  Seeking the cause of the symptom, dysphagia, is, of course, mandatory as nothing can be treated without knowing what brought it about. Treating a headache without finding out whether or not it is caused by tension or tumor is, clearly, absurd. So with dysphagia and it is not sufficient to say, for example, that the patient had a stroke. It is essential to identify, location, type (embolic or hemorrhagic), extent since each will produce different symptoms. 
  No intervention can be undertaken with out a complete examination and that includes the following:
  Age, gender, comorbidities, all medications past and present, history of illness/surgery, immune status, nutrition/hydration status, level of consciousness ? in other words, the complete history.
  Observation and clinical examination is mandatory. Unfortunately, in my experience, the complete examination of the dysphagic patient is never taught leading to the mistaken assertion that clinical examination is not as ?good? as VFS or other instrumental approaches. This is simply untrue but understandable when one reviews the erroneous or absent information being promulgated. For example, since 1988, it has been known and demonstrated that the major protection of the airway is the anterior movement of the arytenoids against the base of the epiglottis  and is related to volume of the bolus Logemann, Jeri A., Peter J. Kahrilas, Joan Cheng,Barbara Roa Pauloski, Patricia J. Gibbons, Alfred W.Rademaker, and Shezhang Lin. Closure mechanisms of
  laryngeal vestibule during swallow. Am. J. Physiol. 262 (Gastrointest. Liver Physiol. 25): G338-G344, 1992.-This study examined the temporal effects of bolus volume on closure of the laryngeal vestibule at the arytenoid to epiglottic base and the mobile portion of the epiglottis, the temporal relationships between these levels of airway closure and cricopharyngeal opening for various bolus volumes, and the mechanisms responsible for these two levels of airway protection during deglutition. Closure of the laryngeal vestibule progressed inferiorly to superiorly at all bolus volumes. Duration of closure of
  the airway at the arytenoid to epiglottic base increased systematically with bolus volume, as did the duration of descent of the epiglottis below horizontal. Closure at the arytenoid to epiglottic base occurred earlier in relation to maximal laryngeal elevation as bolus volume increased. In contrast, descent of the epiglottis to horizontal and the temporal relationship between closure of the airway at the arytenoids.
  Similarly, UES opening has been shown many times to be related directly to the volume of the bolus  See: Upper esophageal sphincter opening and modulation during swallowing. Gastroenterology. 1989 Dec;97(6):1469-78.Jacob P, Kahrilas PJ, Logemann JA, Shah V, Ha T. Nevertheless, I still see patients being given absurdly small boluses that are the most difficult to swallow, with life altering decisions based on these.
  The fact that the hyoid and the arytenoids are so important makes it easy to identify the risk of aspiration. Abnormality of both hyoid movement and arytenoids function by palpation and by presence of certain aspects of dysarthria, as well as abnormal extraocular eye movements make the probability of misdirection of the swallow near certain.
  It must be kept in mind that all diagnoses are made on the basis of education, experience and probability, the potential for error being always recognized, however small.
  I shall continue in the next message as the webmaster will not accept messages that are too large.
Contd next
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Dr I Campbell-Taylor
Clinical Neuroscientist
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