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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
Myotonic Dystrophy Patient Registry
evaluated 556 DM1 patients and their
symptoms, identifying 48% with dysphagia complaints. Those with myotonic symptoms reported dysphagia at
more than twice the rate of those without myotonia (55.3% vs. 21.9%) (Wood
et al., 2017). The pharynx and UES are
the most affected, and intra-deglutitive and post-deglutitive aspiration of
bolus lead to pneumonia. Aspiration
was detected in greater than 50% of
169 patients with MD (Willaert et al.,
2015). Delayed swallowing gestures
and increase transit time have been
associated with increased risk of aspiration (Leonard et al., 2001). In children,
labial weakness also impairs bolus control (Berggren et al., 2018). Pharyngeal
muscle weakness contributes to poor
bolus transit and can be seen on DSS
as an increasing pharyngeal constriction ratio (Leonard et al., 2011). If pharyngeal outlet obstruction is suspected,
then early DSS examination may be
useful to direct treatment and prevent
pharyngeal deterioration.
Myasthenia Gravis
Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular
junction (NMJ). It is caused by antibodies against the muscle membrane
of the NMJ, resulting in inadequate
acetylcholine in the junction and poor
muscle contraction. In 85% of MG
patients, anti-AChR (nicotinic acetylcholine receptor) antibodies are the
cause, but in 5% to 8% of cases, these
are absent, and instead muscle-specific
kinase (MuSK) antibodies are present (Stathopoulos & Dalakas, 2022).
MuSK-positive patients appear to have
greater prevalence of bulbar symptoms
with dysphagia, dysphonia, and dysar-
thria (Stathopoulos & Dalakas, 2022).
In fact, dysphagia may be the presenting complaint in a quarter of patients
with MG (Berrih-Aknin et al., 2014;
Colton-Hudson et al., 2002; Klair et al.,
2014).
Dysphagia is a source of significant
morbidity and mortality in MG, particularly if the underlying disorder is
unrecognized, which is common particularly if nontypical antibodies are
present. Aspiration may occur and be
silent, risking pulmonary health. DSS
findings include abnormal oral control
of bolus with early spill, residue in the
oral and oropharyngeal cavities, slow
pharyngeal transit, and reduced pharyngeal constriction ratio, penetration,
and aspiration (Colton-Hudson et al.,
2002; Yamamoto et al., 2012). In 20 MG
patients complaining of dysphagia, 13
demonstrated penetration during swallow and 7 demonstrated aspiration, of
whom 4 had silent aspiration (ColtonHudson et al., 2002). Manometry demonstrates esophageal hypomotility and
abnormal UES contraction (Stathopoulos & Dalakas, 2022).
Normal rehabilitative strategies such
as exercises are not effective in MG due
to muscle fatigue, and therefore positioning and dietary modifications may
be more appropriate and should be
guided by DSS examination. Medical
therapy is indicated in MG (typically
pyridostigmine, steroids, azathioprine,
or mycophenylate), and assessment on
medication should be considered so
that diet may be adapted for optimal
function. DSS with edrophonium chloride treatment may assist in making
the diagnosis of MG by demonstrating
changes in pharyngeal parameters with
treatment on board (Yamamoto et al.,
2012). Rituximab therapy for MuSKpositive patients is highly effective and
16. NEUROGENIC DYSPHAGIA
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385
indicated as primary treatment in this
group because it depletes B cells in circulation that are producing the autoantibody (Stathopoulos & Dalakas, 2022).
Additional new immune therapies are
in trial and may provide additional
benefit for swallowing.
SUMMARY
Many neurological disorders impact
swallowing safety, efficiency, and vigor.
DSS is a crucial tool in unravelling the
specific abnormalities present and
should be a key feature of full swallowing assessment in these patients.
STUDY QUESTIONS
1. What types of stroke produce dysphagia?
2. Which is more likely to be affected
by stroke: oropharynx or hypopharynx function for swallowing?
DSS in an acute stroke patient?
Should DSS be repeated in acute
stroke patients, and if so, when?
4. What are typical features of dysphagia in head-injured patients?
5. Have significant features of swallowing difficulty been identified for
patients with muscular dystrophy?
Multiple sclerosis? Polymyositis or
dermatomyositis?
6. Do patients with neurological
causes of oropharyngeal dysphagia
respond to swallowing therapy?
7. Do patients with neurological
causes of oropharyngeal dysphagia
respond to surgical therapy?
8. Can DSS help identify who might
benefit most from surgery to
the upper esophageal sphincter
in patients with inclusion body
myositis?
9. If a DSS is recommended for a
patient with Parkinson’s disease,
what might the clinician want to
consider in scheduling it?
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Dysphagia in Head and
https://t.me/medicina_free
Neck Cancer Patients
Katherine A. Kendall
Successful deglutition depends on sensory input from the muscles and the
mucosal surfaces of the oropharynx
to regulate and fine-tune the sequence
of muscular contractions that results
in a swallow. It makes sense that disruption of the sensory, muscular, or
structural integrity of the oral cavity,
pharynx, and larynx causes dysphagia.
In patients with head and neck cancer,
tumor growth, changes in tissue characteristics secondary to radiation with
or without chemotherapy, and any
surgical procedure involving the head
and neck region, therefore, have the
potential to cause dysphagia. Indeed,
xerostomia and dysphagia are the most
often cited contributors to a decrease in
quality of life for head and neck cancer
patients after the completion of treatment (Wang & Eisbruch, 2016). This
chapter will focus on the swallowing
difficulty experienced by head and
neck cancer patients.
INTRODUCTION
In patients with head and neck cancer, interference with normal swallowing may result from the growth of
the tumor-invading structures, impairing their functioning, or from the
obstructive effects of the tumor itself,
which interfere with bolus movement. Surgery to excise the tumor with
a margin of normal tissue typically
results in a defect with loss of structures needed for normal deglutition.
The method chosen for reconstruction
of the defect will subsequently influence the restoration of normal anatomic contours and function. Thus, the
reconstruction affects the character and
the severity of the resultant dysphagia.
When postoperative radiation therapy
is added to the regimen, dysphagia
may worsen secondary to xerostomia
and fibrosis of soft tissues in the field
of radiation exposure, especially if
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