柴田 斉子

OBJECTIVES: Surgical procedure is considered in patients with severe dysphagia when conservative treatment fails. This study aimed to evaluate laryngeal suspension (LS) and upper esophageal sphincter (UES) myotomy for treating severe dysphagia due to brain disease. METHODS: Fourteen patients underwent LS and UES myotomy, with a median follow-up of 5 years and 6 months when conservative treatment failed. The penetration-aspiration scale (PAS), the Dysphagia Severity Scale (DSS), the Eating Status Scale (ESS), and diet contents were evaluated just before surgery, at discharge, and at the last follow-up. RESULTS: Preoperative intake was tube feeding in all patients. The patients learned the extended head and flexed neck posture to open the esophageal inlet. PAS, DSS and ESS scores, and diet contents were significantly improved at discharge compared with before surgery, and were maintained until the last follow-up. Eight patients had pneumonia during their hospital stay, and five had pneumonia between discharge and at the last follow-up. Age was significantly, negatively correlated with DSS and ESS at the last follow-up. CONCLUSION: Although LS and UES myotomy require a long inpatient rehabilitation and the risk of pneumonia after surgery is high, the outcome is favorable and the effects last for a long time.

This study investigated the effects of three different volumes of honey-thick liquid on the temporal characteristics of swallowing. Twenty-six healthy subjects (15 males, 11 females) underwent 320-row area detector CT scan while swallowing 3, 10 and 20mL of honey-thick liquid barium. Three-dimensional images were created at 10images/s. Kinematic events involving six structures (velopharynx, hyoid bone, epiglottis, laryngeal vestibule (LV), true vocal cords (TVC), upper esophageal sphincter (UES)) and timing of bolus movement were timed using frame by frame analysis. The overall sequence of events did not differ across three volumes; however, increasing bolus volume significantly changed the onset and termination of events. The bolus head reached to pharynx and esophagus earlier and the duration of bolus passing through UES was significantly longer in 10 and 20mL compared to 3mL (P<.05). Consequently, the onset of UES opening was significantly earlier with increased volume (P<.05). LV and TVC closure occurred later in 20mL compared to 3mL (P<.05). These changes in motion of pharynx and larynx appeared to promote swallow safety by preventing aspiration, suggesting that anatomical structure movements adapt in response to bolus volume. Our findings also suggest that the pharyngeal swallow behaviours may be modified by afferents in the oral cavity. The three-dimensional visualization and quantitative measurements provided by 320-ADCT provide essential benchmarks for understanding swallowing, both normal and abnormal.

<p>Shibata S, Kagaya H, Tanaka S, Fujii W, Nakagawa K, Matsuo K, Abe K, Ishibashi N, Inamoto Y, Saitoh E. Efficacy of a novel training food based on the process model of feeding for mastication and swallowing: A study among dysphagia patients. Jpn J Compr Rehabil Sci 2017; 8: 82-87.</p><p><b>Objective</b>: Our goal was to verify the validity and safety of chew-swallow managing food (CSM) for dysphagia patients.</p><p><b>Methods</b>: We conducted a study on 14 inpatients diagnosed with dysphagia and judged to be capable of ingesting pureed foods. We instructed each participant to ingest and freely swallow 4-g samples of CSM and pureed food. For each sample, we measured the number of chewing cycles, number of swallows, position of the leading edge of the bolus at the time of swallowing initiation, amount of residue in the oral cavity and pharynx, and occurrence of laryngeal penetration or aspiration.</p><p><b>Results</b>: The number of chewing cycles was significantly higher for the CSM. The position of the leading edge of the bolus at the time of swallowing initiation was primarily in the valleculae for both the CSM and pureed food, and the rate of laryngeal penetration did not significantly differ between the two test foods. There was a high rate of residue on the dorsum of tongue with the CSM and in the valleculae with the pureed food.</p><p><b>Conclusion</b>: The CSM induced chewing in dysphagia patients, and the prevalence of penetration did not differ from the pureed food. Therefore, we concluded that the CSM could be used in chewing exercises with the same level of safety as the pureed food.</p>

Preswallow bolus formation usually occurs in the mouth for liquids and in the oropharynx for solid foods. We examined the effect of chewing on the relationship between bolus transport and swallow initiation. Fifteen healthy subjects were imaged with lateral projection videofluorography while eating liquids, solid foods, and a mixture of liquid and solid foods in upright and facedown postures. Videotapes were reviewed to measure the location of the leading edge of the barium at swallow initiation. Chewing and initial consistency each altered the relationship between food transport and swallow initiation. In particular, when chewing liquid (or consuming foods with both liquid and solid phases), a portion of the food commonly reached the hypopharynx well before swallow onset. This transport to the hypopharynx was highly dependent on gravity, but transport to the valleculae for chewed solid food was active, depending primarily on tongue-palate contact. Chewing appeared to reduce the effectiveness of the posterior tongue-palate seal, allowing oral contents to spill into the pharynx. Consuming two-phase foods with both solid and liquid phases may increase the risk of aspiration in dysphagic individuals with impaired airway protective reflexes.

【目的】2002年に我々は,液体を含む食物における咀嚼条件下での嚥下動態を観察し,嚥下反射開始前に食塊が下咽頭にまで達する現象を報告した.この結果から咀嚼が嚥下反射惹起を抑制する可能性を考え,本研究では咀嚼が嚥下反射惹起に与える影響および,咀嚼嚥下時の喉頭・咽頭の内視鏡所見を明らかにすることを目的とした.【対象・方法】対象は健常成人9名(平均年齢28.8歳)である.左鼻腔より4Frエラスティックチューブを挿入し,先端が口蓋咽頭筋に達する位置で固定した.緑色に着色した飲料水をシリンジポンプを用いて6.5ml/min,11.5ml/minの速度で注入した.舌骨上筋群の筋電図を記録し,喉頭内視鏡にて液体の流れを観察してビデオテープに録画した.注入速度,咀嚼有無,がまん有無の8条件において液体注入開始から嚥下反射惹起までの時間を計測した.【結果】液体注入開始から嚥下反射惹起までの時間は,注入速度およびがまんの有無の間に著しい有意差を認めたが,咀嚼の有無の間には差を認めなかった.嚥下を我慢すると,披裂が前傾,強内転し,咽頭腔が拡大する現象がすべての被験者に認められた.随意嚥下では液体が咽頭喉頭蓋ひだに達すると,あるいは片側梨状窩の半分を満たすと嚥下反射が惹起された.嚥下をがまんさせると,液体が梨状窩を満たし,披裂喉頭蓋ひだや披裂陥凹をこえて喉頭に液体が流入しようとする時点で嚥下反射が惹起された.【考察】咀嚼は液体注入時の嚥下反射惹起までの時間に影響を与えず,咀嚼が嚥下反射を抑制するとした仮説は否定された.嚥下をがまんするという意志による嚥下抑制課題は,誤嚥を防ぐために下咽頭の容積を増大させる能動的な咽頭の形態変化を生じさせることがわかった.これらの新たな知見を摂食・嚥下障害のリハビリテーション手法に応用することが,今後の課題である(著者抄録)

健常成人10名を対象として嚥下反射開始前に起こる下咽頭への食塊輸送に対する咀嚼と重力の影響を検討した.バリウム水溶液(液体)10ml,バリウム含有コンビーフ(コンビーフ)8g,液体5ml・コンビーフ4gの混合物(混合)を,座位,よつばい位の2体位で咀嚼させ,ビデオ嚥下造影(VF)を各2回ずつ試行した.その結果,座位において嚥下反射開始直前の食塊の深達度は喉頭蓋谷部Valleculae(VAL)+下咽頭Hypopharynx(HYP)で,混合と他の2食物間で有意差を認めた.更にHYPでは全食物間で有意差を認めた.よつばい位において食物の違いによる深達度の有意差を認めなかった.座位とよつばい位を比較した結果,コンビーフでは体位を変化させても食塊先端位置の分布は殆ど変わらなかった.液体では有意差は認めなかったもののよつばい位においてHYPまで達する頻度が減少傾向にあった.混合では座位に較べてよつばい位でVAL+HYP,HYPに達する率が有意に減少した

咀嚼嚥下の評価法の確立のため,健常成人10名を対象として,4食物条件下で咀嚼が嚥下反射開始前の食塊位置および嚥下時間経過に及ぼす影響を嚥下造影検査を用いて検討した.液体命令嚥下に比し全咀嚼条件で食塊先端位置の中～下咽頭への到達率が高く,食塊進入には咀嚼の存在が一義的に関与し,食物形態はそれを修飾する役割を担うと思われた.混合咀嚼条件では食塊は全例で嚥下前に中～下咽頭へ到達しており,信頼性の高い負荷法といえた.液体を含む咀嚼嚥下では,下咽頭到達が高率で下咽頭通過時間も長く,誤嚥防止の観点から興味深い所見であった.咀嚼嚥下は命令嚥下とは別様式であり「食べる」機能の評価と位置づけられた.