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    10 views6 pages

    Ooa 00127

    Uploaded by

    Marcia Santana

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    © All Rights Reserved
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    SS Hyoid Movement During Swallowing in Older Patients With Dysphagia Katherine A. Kendall, MD; Rebecca J. Leonard, PhD Objectives: To describe the timing, coordination, and extent of hyoid movement in a population of ol der adults with dysphagia and to evaluate the effect of hyoid movement on upper esophageal sphincter ‘opening. Designs A retrospective review of dynamic swallow stud- ies performed between January 1996 and December 1099 was done. ‘Subjects: Patients included in the study were 65 years fo older, without an obvious medical or surgical cause for their dysphagia. Timing and distance measures ‘of hyoid movement from the patient population were compared with those from 60 younger (range, 18-62 years) and 23 older (range 67-83 years) control subjects without dysphagia using I-way analysis of variance Analysis of the effect of hyoid movement on upper esophageal sphincter opening was performed using contingency tables. Results: In an older population with dysphagia, the co- ordination of swallowing gestures and bolus timing wasin- tact, hyoid elevation was slow, and the duration of ‘maximal hyoid elevation was reduced, but appropriate for the age ofthe patents. The hyoid bone elevated farther than normal for stall bolus sizes, but the patients were unable {o maintain this strategy in larger bolus swallows. Conelusion: An increased extent of hyoid displace- ‘ment in older patients with dysphagia may represent a necessary compensation designed to minimize the effect of the short duration of hyoid elevation on the upper esophageal sphincter opening, Arch Otolaryngol Head Neck Surg. 2001;127:1224-1229 LTHOUGH swallowing im- pairment occurs inal age ‘groups, older persons rep- resent the largest affected group. Isolated swallow- ing ofthe upper esophageal sphincter (UES) and is readily measured from a videofluo- roscopie dynamicswallow study. The tim- {ng and extent of hyoid elevation were in- chided in the analysis, In addition, the coordination of hyoid motion with move- From the Department of Otolaryngolagy, University of California, Davis, Medical Center, Sacramento ing difficulties are present in a substan tial percentage of older adults, and a com- ‘mon sequela of dysphagia in thisage group {s aspiration, with subsequent pneumo- nla. The prevalence of dysphagia ts 50% fm nursing homes." Furthermore, the in- idence of identifiable swallowing abnor- malities is greater in older patients with dysphagia compared with younger pa- tients who have swallowing difficulties, The clinical effects of dysphagia in older persons warrant an in-depth analysis of the specific types of abnormalities occurring {n this patient population, Although muliple swallowing abnor- malities are likely to he present in patients with dysphagia, this study focuses on hy- oid function in a population of older pa- tients with dysphagia. The hyoid bone moves during swallowing as result of su- prahyoid muscle contraction,"* Hyoid ‘movement is required for adequate open- (©2001 American Med jamanetwrork.com/ on 03/21/2019 ‘ment of the bolus through the pharynx and the effect of hyoid movement characteris- tics on UES opening were assessed. The evaluation ofthe coordination of swallow- ing gestures relative to bolus transit en- ables us to identify cases in which gesture timing is altered secondary to pathologic conditions or is used as a strategy to over- ‘come functional abnormalities, xl! Differences in the timing and extent of hy- od bone elevation between the patient population and younger controls were ide ified inthis study. However, when the data from the patient population were com- pared with those from the older controls, ‘more subile differences were identified The onset of hyoid elevation (H1) relative to the onset of bolus pharyngeal 1 Association, All rights reserved. MATERIALS AND METHODS Dynamic swallow studies performed between January 1996 td December 1900 yerefeviewed.Thosestides om pe itnts 63 years or older witha primary diagnose of dys- Phagla of unknown etiology were included in he study. A Primary daghosts of dysphagia of unknown etiology was Acsignated if he patient had no other obvious diagnose that could cause dysphapi, such se neuromuscular dis case or recent stroke ‘The radiographic studies were conducted in the Voice- speech Swallowing Center at University of California, Davis, Medical Centr, Sacramento, in accordance withthe rou: tineradiographic protocols proved by the imstuon, Equip tment used included a propery collimated radiographic and fuoroscopic unit (Philips Medial Systems North America Co, Shelia, Conn tha provides a 6-4V, 1 2-ma lp for the full feld-otview mode (22-9-cm input phosphor diameter). Fluoroscopy studies were recorded on high- ually videotape for playback and analysis using a vdeo- Cisseile VHS recorder and player (node! 1380, Sony Cor- poration of America, New York,NY). graphic time display Provided by a character generator (RCA Corp Indianapolis, Tha) and an alerating curren adapter (mal C412. JVC. ‘Wayne, NJ) were included on the videolape, 0 tha ting informational 001-second intervals was recorded, Theswal lowing studies were recorded 3 rames per second, Mea- surements were made during the swallowing of mand orm liquid bluse (Liquid Barospere ari lates pension; Lafayette Pharmaceual, Ine Anahi, Cali Max {cial to be allowed was presented tothe subject by cup. “The videotaped imager were later captured vith adigi- ting board (Data Translation, Ine, Matlbor, Mass) and computes (PPC 9500, Macintosh; Apple Computers, Cu peti, Cai. sotvareprogramin the publicdomain n- fgeavalableat hsb nfo gownmage, developed iy Wayne Rasbond MS, and colleagues, Nations inst of Mental Health, Bethesda, Ma was used for analyst of ho- rescopicimages, Distance mensrements were nad alr cal bration of the digitized image tothe sizeof the 17-cm- diameter wire lop taped to the chin ofthe study subject. ‘all measurements were cbialned rom lateral views A deualled technical description of thee measures and thet Acquisition has been previously published” and tbrely summarized herein. Maximal hyoid elevation was mea- ured asthe distance between te yok! postion at bolus “hol,” e, when the bolus shed inthe oral avity and ite Point of maximal anterior and superior excursion during the swallow, The fst superior-anterior movement of the hyoid that resulted na swallow was designated HL H2 was the point at which te hyoid achieved maximal displace tment during the swallow. The instant the hyoid began ie descent oa resting postion was designated H3, The ime required for hyoid elevation (H2-H1) and the duration of ‘maximal hyoid elevation (H3-H2) can he calculated Bolus pharyngeal ransit time was defined a theme between the onset al completion of bolus pharyngeal tran SL The oct of pharyngeal transit was designated BL and twas defined a theft movement ofthe hea of the bols from stable, or “hold,” poston that pase the posterior ‘sal spine and resuled nal or part of te bolus entering the oropharynx. The posterior nasal spine located atthe end of the ard palate and fsa good landmark fr the an- terior border ofthe oropharynx, Pharyngeal transit was Continued of next page transit (B1) was delayed in the patient population com- pared with the younger contrals for both bolus catego- Hes. HI was also delayed in the older control group, but not to the extent found in the patient group (Table 3) The point at which the hyoid reached maximal eleva tion (H2) and the point at which the hyoid began its de- scent back to a resting position (H3) were similarly de- layed inthe patient population compared with the younger controls. Again, the timing of these events relative to the ‘onset of bolus pharyngeal transit was delayed in the older ‘controls compared with the younger controls, but not to -xtent found in the patient group (Fable 4 and Table 5). Some delay in the timing of hyoid move- ments is expected in older persons. Although the differ- ‘ence in data between the patient group and the alder con- trols did not reach statistical significance, a trend toward _greater delays in the patient population was identified To evaluate the coordination of hyoid movement with. the position of the bolus in the pharynx, Hi was com pared with BV. In younger persons without swallowing abnormalities, the hyoid begins to elevate just after the ar- rival of the bolus in the vallecula.” In the patient popu lation and in the older controls in our study, this relation- ship Was maintained for the I-mL bolus. For the 20-mL_ bolus in the patient group, the hyoid bone began to el- cevate early relative to the arrival of the bolus in the val- lecula (Table 6). To summarize, coordination of hyoid (©2001 American Med jamanetwrork.com/ on 03/21/2019 clevation with the position ofthe bolusin the pharynx was normal or slightly early in the patient population, ‘Once hyoid elevation began, the time requited for the hyoid to reach maximal elevation (H2-H1) was pro- longed in the patient population relative to the younger controls for both bolus categories. When the patient popt- lation was compared with the older controls, no differ- ence in H2-H1 was identified 17). The hyoid was held maximally elevated (H3-H2) for a shorter duration in the patient population and in the older control group for the 1-mL. bolus, and tended toward shorter duration of elevation for the 20-mL_ bolus (Fable 8). The dura- tion that the hyoid was elevated (H3-H1), however, was, not significantly different among the 3 groups (Table 9). Becatise the patients and the older control subjects took longer to elevate the hyoid bone maximally and held it clevated fora shorter duration, compared with the younger controls, itis possible that this difference is due toaging, rather than pathophysiologic conditions. To determine ifthe shorter duration of maximal hy- old elevation (H3-H2) corresponded directly to longer times required to achieve the maximal position (H. HD), bolus-specific regression analysis comparing the 2 variables in individual patients was performed. No di- rect relationship was identified The extent of hyoid displacement was analyzed separately for men and women, because of previously 1 Association, All rights reserved. complete when the tail ofthe bolus was fly within the UES! Pharyngel transit time canbe divided into an oro- Sharyngeal and a ypopharyngeal phase by the srival of {he bol in the vallecula (BV) If the bos bypasced the tallecula the time when the bolis passed the level ofthe base of the vallecula was designated BY. Hyoid movement relative to the onset of bolus pharyngeal transit (HI-B1) snd relative tothe areval ofthe bolus nthe vallcula (H1- BV) cam be callated. Maximal opening of the UES was measured atthe nar rowest part ofthe upper csophagusbetween Cand Co dur ing maximal distension, We believe that this point best de- fines the location of the UES i also reliably identified on a dynamic swallow study, as opposed to a measure- tment made from the often poorly defined tp of the air col tim inthe trachea” “The data rom the measured variables were averaged across subectsacconding to bolussize. Fallen means were then compared with the means from dynamic videoluo- roscopic swallow studies performed on 60 volunteers with bout fephagin aged 18063 yeas and with he means fromm studies performed on 25 older volunicers without dyspha- gia aged 67 to 9, using -vay analyst of variance, Post {ests were done to evalunte differences between individual pats of groups, A Bonferront correction wa applied to ake Into account that multiple comparisons were performed The overall Pvalue, the uncorrected P values determined from comparisons between groups, and the Bonferroni cor rected P values ae reported “The younger contol group consisted of 30 men nd 30 women, There were 10 men and 13 women inthe older Control group: None ofthe contol subjects had symptoms of dysphagia or gastroesophageal reflux disease, abistory of central nervoussystem or craniofacial bnormaliles or other ‘medical problems. They tol nomedicatons aloft con- trols were respondents to advertisements asking fr volun- {cerstopaticpatein the study. Sereening of prospective par Ailpant was are out to ensure they tthe study entra Each volunteer was examined to rule out potential sna- {omic abnormalities inthe head and neck region. “The relationship of speci wallowing gestures to one another in indivial pallets was analyzed sing linear re session. Any abnormality in the opening sce ofthe UES trae noted for each patient and wat defined as les than 2 5s from the mean ofthe younger contol Fisher exal est Contingency ables were sed to analyz the relationship be tween UES opening sz and duration of kyoid elevation, Duting the study, 1313 dynamic swallow tues were performed. Of those, 301 (27.5%) were performed in in- viduals years or older. The daghostic ategorisin the patent population ar sted in Table 1. Only patients in Theirs category. nonspecific dysphagia, were included in the study, When subsequent studies nthe same individu ts were excluded, the inal number of patients included inthestudy was 05 (age range, 65-9 yes). Only # of the 65 patients (12%) did not have atleast one other medical problem, such as hypertension, diabetes, or arthritis 'Notal patients had complete data avalable for analy sis, Hyoid placement data were offen avallable for only one bolus size per patient. Reported results include the nm ter of patients with das avalable foreach measured vat ale, A‘swallow study variable was defined as normal fi twas within 2 Deo the normal mean Fr esc of compat on, rests fom conirl subject are reported nthe ables Mongsde those rom the patents. Ais ofabbrevtons used inthe text is provided in Fable 2 for reference. identified sex differences in this variable.® Women in the patient population elevated the hyoid much farther than did younger female controls for the I-ml bolus, and to a normal extent for the 20-ml bolus. The older female con- trols also elevated the hyoid bone toa greater extent for a 1-ml bolus than did younger female controls, but not to the extent found in the female patients (Rabble 18). A re: view of individual data revealed that none of the women ‘with dysphagia had decreased hyoid elevation during a L-mL swallow. Four of the women had decreased hyotd elevation on # 20-ml bolus, but the overall means from, the 3 groups were not significantly different Men with dysphagia also demonstrated greater than normal hyoid elevation during.a I-mL bolus swallow com- pared with younger male controls, but the difference did not reach statistical significance. The older male con- trols also elevated the hyoid bone farther than the younger male controls, but not to the extent found in the men ‘with dysphagia. Data on hyoid elevation during a 20-mL bolus swallow were available for only 5 male patients. Three ofthese patients had decreased hyoid elevation dur- ing the swallow of the larger bolus, and the overall mean ‘was significantly less than those from the younger and older control groups (Table 11) The distance of hyoid bone elevation is usually _greater for the larger bolus eategories, Patients elevated, the hyoid bone significanily farther than normal during (©2001 American Med jamanetwrork.com/ on 03/21/2019 ‘small bolus swallow. Perhaps, this finding represents a strategy that compensates for other abnormalities. It vas also seen, but to a lesser extent, in the older control group. However, on the larger bolus swallows, the pa- tent population could not maintain this strategy, and the distance of hyoid elevation diminished to normal or be- low normal levels. Although the difference identified in the older control group did not reach statistical signi cance, a trend toward farther elevation of the hyotd dur- ing a larger bolus swallow was found, To determine ifthe prolonged lime required for the hyoid to reach maximal elevation was directly related toan inereased distance of hyoid elevation, regression analysis comparing bolus specific H2-H1 ineach patient to the dis- tance of hyoid elevation in that patient was performed. The analysis failed to reveal a consistent relationship, however. Similar analyses did not dently any relationship between the duration the hyoid was held at maximal elevation (H3- #2), the duration of hyoid movernent (H3-H1) and the ex- tent of hyoid displacement in individual patients, ‘A Fisher exact test revealed that decreased extent of hyoid elevation was statistically related to a de- creased maximal opening of the UES (P=.004). The con- verse was not true. That is, greater hyoid elevation was, not correlated with a larger UES opening size. No cor- relation was found between the distance or duration of hyoid elevation and the duration of UES opening, 1 Association, All rights reserved. ‘Table 1. Diagnostic Categories in 364 Patents no.) oan, Hinepaciedaphapa 7o (tea) ‘eu cerebral vsclraciant (104) Papers neuropathy Res) Carta aurea canton 30,108) Pulmonary problems 2404) Vocal od paresis. nea Head ad neck cancer 14 (28.8) Ober 19163) ‘Table 2. Abbreviations Gasset Betton a ‘rsa of pharyngeal bolus transit wv va ofthe olin he valcla Mt Onset of yodelevaton we Time at which hoi reaches maxima alavaton i rsa of yo dosent to rsting postion ‘Table 3. Onset of Hyold Elevation (H1-B1) stuyaroup ‘ean 80 wo! ‘Meanss0 Pater Dste087 2 o4va0as a0 Yourgerconrols 0252029 600182017 60 Oierconos = 0402040 22074017 | 28, Bt mate > eontronl’ " P— Gonteren! comparsen Value Pale Value Pale Drea P val oF Patents vs yourgerconols <001 <1 Patents lr eontale 12 Younger veoderconrols 33 Elias neta ot plea. In summary, although the timing of hyotd eleva tion in the patient population was delayed relative to the onset of bolus pharyngeal transi, this was also found in the older control group. Only a rend toward greater de- lays in the patient population compared with the older controls was identified. Likewise, the increased time in the patient population required 1o achieve maximal hy- oid elevation once elevation was initiated, and the de- creased duration the hyoid was held at maximal cleva- tion, was also found in the older controls, No inverse relationship between the time required to reach maxi- mal elevation and the duration of maximal elevation was found, although the overall duration of hyoid move- ment (H3-H1) did not differ between any of the groups. The coordination of hyoid elevation with the arrival of the bolus in the vallecula was maintained in the older ‘groups for I-mL boluses, and was early relative to the arrival of the bolus in the vallecula in the patient pop ©2001 American Medi jamanetwrork.com/ on 03/21/2019 Assoc Table 4, Hyold Reaches Maximal Elevation (2-81) sway orp Means 80 Wo we Pater 70e209 6007.03 40 Youngercontols 0582029 60 a47z016 60 Oldrcontols = 0792037 «23 aySe021 23 1 Ana Peoneronl comparison Value —PYalua Value ‘vara P wae 012 OOF Patents veyoungercone <001 9) <1 < 004 Patents ve oer eorrle 07 st Yourgrvsclecconrols 17 oo <001 lips at data ot appeal, Table 5. Onset of Hyold Descent (H3-B1) sway orup ‘Mean +80 Wo Pater 102068 at Youngercontols 0702030 59 ag7s017 60 Oldrcontols = 0922037 © -23—=aBe020 23. WS Ana Peoneronl comparison value _PValua value ‘veal Paes one O07 Patents veyoungerconle 001 <1 <0) < 001 Patents reo. 13, 21 Younger vsoiecconrols 24 oo eontronl’ " P— Gonteren! comparsen Value Pave Value Pale imal Paes 15 O08 Patents yourgerconls 02 om

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