Assessment of swallowing and referral to speech and language therapists in acute stroke.
The best clinical assessment of swallowing following acute stroke, in order to decide whether to refer a patient to a speech and language therapist (SLT), is uncertain. Independently of the managing clinical team, we prospectively investigated 115 patients (51 male) with acute stroke, mean age 75 years (range 24-94) within 72 h of admission, using a questionnaire, structured examination and timed water swallowing test. Outcome variables included referral to and intervention by a speech and language therapist (SLT), dietary modification, respiratory complications and death. Of those patients in whom an SLT recommended intervention, 97% were detected by an abnormal quantitative water swallowing test; specificity was 69%. An SLT was very unlikely to recommend any intervention if the test was normal. Inability to perform a water test and/or abnormality of the test was associated with significantly increased relative risks of death, chest infection and dietary modification. A timed water swallowing test can be a useful test of swallowing and may be used to screen patients for referral to a speech and language therapist after acute stroke. (+info)
Swallowing function after stroke: prognosis and prognostic factors at 6 months.
BACKGROUND AND PURPOSE: Swallowing dysfunction (dysphagia) is common and disabling after acute stroke, but its impact on long-term prognosis for potential complications and the recovery from swallowing dysfunction remain uncertain. We aimed to prospectively study the prognosis of swallowing function over the first 6 months after acute stroke and to identify the important independent clinical and videofluoroscopic prognostic factors at baseline that are associated with an increased risk of swallowing dysfunction and complications. METHODS: We prospectively assembled an inception cohort of 128 hospital-referred patients with acute first stroke. We assessed swallowing function clinically and videofluoroscopically, within a median of 3 and 10 days, respectively, of stroke onset, using standardized methods and diagnostic criteria. All patients were followed up prospectively for 6 months for the occurrence of death, recurrent stroke, chest infection, recovery of swallowing function, and return to normal diet. RESULTS: At presentation, a swallowing abnormality was detected clinically in 65 patients (51%; 95% CI, 42% to 60%) and videofluoroscopically in 82 patients (64%; 95% CI, 55% to 72%). During the subsequent 6 months, 26 patients (20%; 95% CI, 14% to 28%) suffered a chest infection. At 6 months after stroke, 97 of the 112 survivors (87%; 95% CI, 79% to 92%) had returned to their prestroke diet. Clinical evidence of a swallowing abnormality was present in 56 patients (50%; 95% CI, 40% to 60%). Videofluoroscopy was performed at 6 months in 67 patients who had a swallowing abnormality at baseline; it showed penetration of the false cords in 34 patients and aspiration in another 17. The single independent baseline predictor of chest infection during the 6-month follow-up period was a delayed or absent swallowing reflex (detected by videofluoroscopy). The single independent predictor of failure to return to normal diet was delayed oral transit (detected by videofluoroscopy). Independent predictors of the combined outcome event of swallowing impairment, chest infection, or aspiration at 6 months were videofluoroscopic evidence of delayed oral transit and penetration of contrast into the laryngeal vestibule, age >70 years, and male sex. CONCLUSIONS: Swallowing function should be assessed in all acute stroke patients because swallowing dysfunction is common, it persists in many patients, and complications frequently arise. The assessment of swallowing function should be both clinical and videofluoroscopic. The clinical and videofluoroscopic features at presentation that are important predictors of subsequent swallowing abnormalities and complications are videofluoroscopic evidence of delayed oral transit, a delayed or absent swallow reflex, and penetration. These findings require validation in other studies. (+info)
Hypoglossal nerve injury as a complication of anterior surgery to the upper cervical spine.
Injury to the hypoglossal nerve is a recognised complication after soft tissue surgery in the upper part of the anterior aspect of the neck, e.g. branchial cyst or carotid body tumour excision. However, this complication has been rarely reported following surgery of the upper cervical spine. We report the case of a 35-year-old woman with tuberculosis of C2-3. She underwent corpectomy and fusion from C2 to C5 using iliac crest bone graft, through a left anterior oblique incision. She developed hypoglossal nerve palsy in the immediate postoperative period, with dysphagia and dysarthria. It was thought to be due to traction neurapraxia with possible spontaneous recovery. At 18 months' follow-up, she had a solid fusion and tuberculosis was controlled. The hypoglossal palsy persisted, although with minimal functional disability. The only other reported case of hypoglossal lesion after anterior cervical spine surgery in the literature also failed to recover. It is concluded that hypoglossal nerve palsy following anterior cervical spine surgery is unlikely to recover spontaneously and it should be carefully identified. (+info)
Palliation of dysphagia from inoperable oesophageal carcinoma using Atkinson tubes or self-expanding metal stents.
Until recently, intubation for the palliation of malignant dysphagia has relied upon the insertion of a variety of plastic tubes. Self-expanding metal stents are reported to have a lower complication rate. We have compared the results of Atkinson tube insertion with self-expanding metal stents in patients with inoperable oesophageal carcinoma. From 1990 to 1994 Atkinson tubes were inserted for the palliation of dysphagia from oesophageal cancer, from 1994 onwards self-expanding metal stents were used. Complications, mortality and hospital stay were compared in both groups of patients. In all, 87 patients with inoperable oesophageal carcinoma were treated, 46 with an Atkinson tube and 41 with metal stents. Complications occurred at similar rates in both groups (56% Atkinson tubes, 44% metal stents). There was a significantly higher perforation rate associated with Atkinson tube insertion (8 patients, 17%) compared with metal stents (1 patient, 2.4%, P = 0.02, chi 2). The length of stay was also significantly higher in the Atkinson tube group (median 10 days) compared with the metal stent group (3 days, P < 0.01, Mann-Whitney U test). Mortality rates were similar in both groups. The use of metal stents for the palliation of dysphagia in inoperable oesophageal carcinoma results in a lower perforation rate and a reduced length of stay and they represent a significant advantage over Atkinson tubes. (+info)
Radiation-induced esophageal carcinoma 30 years after mediastinal irradiation: case report and review of the literature.
A 54-year-old man who had been irradiated in 1964 for cervical involvement by Hodgkin's disease was admitted in December 1994 to our clinic with strong complaints of dysphagia. The reason was a moderately differentiated squamous cell carcinoma of the proximal esophagus in the previously irradiated region. The patient had no risk factors (abuse of nicotine or alcohol) for the developement of esophageal carcinoma. A reirradiation was performed, but the disease progressed locally and two weeks after the beginning of the therapy the patient developed two tracheoesophagocutaneous fistulae. The radiation therapy was discontinued and the tumor stenosis was bridged by a tube closing the fistulae. A retrospective dose analysis to evaluate the applied doses will be performed. Furthermore, an overview of 66 cases of the literature with radiation-induced esophageal carcinoma analysed concerning applied dose and latent interval will be given. In conclusion the reported case fits the criteria for radiation-induced malignancies (Chudecki Br J Radiol 1972;45:303-4) known from literature: (1) a history of previous irradiation, (2) a cancer occurring within the irradiated area, (3) gross tissue damage due to an excessive dose of radiation, and (4) a long latent interval between irradiation and development of cancer. Esophageal carcinomas belong to the rare secondary malignancies after the therapeutic use of ionizing radiation. Nevertheless in patients with dysphagia they should be suspected as a differential diagnosis even many years after mediastinal irradiation. The treatment of these tumors is very difficult and is associated with a poor prognosis. (+info)
Feeding problems in merosin deficient congenital muscular dystrophy.
Feeding difficulties were assessed in 14 children (age range 2-14 years) with merosin deficient congenital muscular dystrophy, a disease characterised by severe muscle weakness and inability to achieve independent ambulation. Twelve of the 14 children were below the 3rd centile for weight. On questioning, all parents thought their child had difficulty chewing, 12 families modified the diet, and 13 children took at least 30 minutes to complete a meal. On examination the mouth architecture was abnormal in 13 children. On videofluoroscopy only the youngest child (2 years old), had a normal study. The others all had an abnormal oral phase (breakdown and manipulation of food and transfer to oropharynx). Nine had an abnormal pharyngeal phase, with a delayed swallow reflex. Three of these also showed pooling of food in the larynx and three showed frank aspiration. These six cases all had a history of recurrent chest infections. Six of eight children who had pH monitoring also had gastro-oesophageal reflux. As a result of the study five children had a gastrostomy, which stopped the chest infections and improved weight gain. This study shows that children with merosin deficient congenital muscular dystrophy have difficulties at all stages of feeding that progress with age. Appropriate intervention can improve weight gain and reduce chest infections. The severity of the problem has not been previously appreciated in this disease, and the study shows the importance of considering the nutritional status in any child with a primary muscle disorder. (+info)
Posterior dislocation of the sternoclavicular joint is a relatively rare injury and can be difficult to diagnose acutely. We report 3 cases of posterior dislocation of the sternoclavicular joint who presented to the Accident & Emergency Department within a 3 month period. All 3 patients had sustained a significant injury to the shoulder region and complained of pain around the medial clavicle. Two patients had also complained of dysphagia following the injury. Plain X-rays of the shoulder and chest were reported as normal by junior and senior medical staff. The diagnosis was delayed until CT scans were performed, and once this was established, open reduction and stabilisation was performed. (+info)
Octreotide in refractory functional epigastric pain with nutritional impairment--an open study.
AIM: To test the therapeutic efficacy of octreotide administered subcutaneously for the relief of chronic refractory epigastric pain severe enough to provoke nutritional impairment. SUBJECTS AND METHODS: Seventeen patients were enrolled in an open trial. Epigastric pain had lasted from 1 to 8 years (median: 5 years), following anti-reflux surgery in eight patients. Median weight loss was 10% (range 10-15). The initial dose of octreotide was 50 microgram b.d, adjusted during the follow-up visits which were scheduled for months 1, 3, 6, 8, 10, 12 and every 3 months. At each visit, overall symptomatic improvement, frequency and intensity of symptoms were checked on a 10-cm visual analogic scale. RESULTS: At month 1, a progressive improvement of pain intensity was reported in 15 of the 17 patients, while octreotide was a therapeutic failure in two. In four out of 15, the daily dose of octreotide was increased to 100 microgram b.d. In these 15 patients, median follow-up was 7 months (3-27). The symptomatic benefit was maintained in each patient at month 3, with a median weight gain of 3.5 kg.2-5 An attempt to stop octreotide led to recurrence of symptoms in 2-3 days which were as intense as before the treatment. The 11 patients followed-up for at least 6 months reported persistent improvement of symptoms with octreotide and a median weight gain of 4 kg.3-7 Four patients were followed up for more 11-27 months: octreotide was withdrawn gradually in two who remained asymptomatic. Six of the 17 patients experienced minor side-effects, but none developed biliary sludge. CONCLUSIONS: This open study suggests that octreotide could be a promising alternative treatment when all others fail in refractory chronic functional epigastric pain severe enough to limit food intake and to induce nutritional impairment. These results must be tested by a placebo-controlled study. (+info)