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Dysphagia in Wilson’s Disease: A Case Report of One-Year Follow-Up

Doyoung KIM ; Yoon Ghil PARK ; Jung Hyun PARK ; Jinyoung PARK

Journal of the Korean Dysphagia Society.2021;11(1):82-86. doi:10.34160/jkds.2021.11.1.012

Wilson’s disease (WD) is a genetic disease caused by an ATP7B gene mutation. Although dysphagia is known as a neurological manifestation of WD, clinical case reports with post-treatment long-term follow-up are scarce. A 17-year-old male was admitted to hospital complaining of general weakness and swallowing difficulty. He was diagnosed with WD by genetic confirmation. Assessment of the videofluoroscopic swallowing study (VFSS) determined an initial videofluoroscopic dysphagia scale (VDS) score of 48. After 11 months treatment with D-penicillamine and neuromuscular electrical stimulation therapy (NMES) with oromotor exercises, the VDS score improved to 23, especially in the following areas: mastication, apraxia, premature bolus loss, triggering of pharyngeal swallow, and laryngeal elevation. Dysphagia is an early neurological symptom of WD, and is reversible when properly treated with early diagnosis. Thus, since WD is treatable, patients presenting with dysphagia should be indicative of high probability of the disease, and evaluated at the earliest. NMES treatment in combination with D-penicillamine helps to improve the deglutition function in both oral and pharyngeal phases. To investigate the characteristics of dysphagia and the specific clinical efficacy of NMES in WD, further studies with larger number of patients are required.

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Respiratory Arrest Induced by Presbyesophagus: A Case Report

Yong Sung JEONG ; InHyuk SUH ; Jong Keun KIM ; Jin Seok BAE ; Jong Youb LIM

Journal of the Korean Dysphagia Society.2021;11(1):78-81. doi:10.34160/jkds.2021.11.1.011

Presbyesophagus is a unique cause of dysphagia in the elderly, which features incomplete relaxation of the lower esophageal sphincter, dilatation of the esophagus, decreased esophageal peristaltic pressures, abnormal esophageal contractions, and delayed emptying of the esophagus. An 88-year-old woman underwent surgery for a femur fracture.The day after surgery, respiratory arrest occurred during a meal. Breathing resumed after oxygen supply with airway opening. She complained of dysphagia and nausea during a meal, and the videofluoroscopic swallowing study and esophagography showed delayed emptying of the esophagus, abnormal esophageal contraction, and dilatation of the esophagus. This case shows that esophageal dysfunction in the elderly with poor general medical conditions can worsen abruptly.

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Dysgeusia as Anti-GQ1b Antibody Syndrome with Brainstem Involvement: A Tractography Case Report

Yeonjae HAN ; Young Kook KIM ; Geun-Young PARK ; Sang Ah JEONG ; Sun IM

Journal of the Korean Dysphagia Society.2021;11(1):72-77. doi:10.34160/jkds.2021.11.1.010

Dysgeusia and dysphagia are rarely reported as the sole clinical symptoms of anti-GQ1b antibody syndrome involving the cranial nerves (CN). According to previous reports, those exhibiting bilateral facial nerve palsy or ophthalmoplegia or both are followed by bulbar dysfunctions (CNs IX and X). This paper reports a case of a 22-year-old man showing dysgeusia with dysphagia and mild limb weakness. Fiberoptic endoscopy revealed signs of residues after swallowing. The nerve conduction study (NCS) in the limbs and conventional brain magnetic resonance imaging were normal. Further workup revealed a positive serum anti-GQ1b antibody. The diffusion tension weighted brain images with tractography revealed involvement to the bilateral corticobulbar and corticospinal tract at the brainstem level. Although his normal NCS and conventional brain MRI made the diagnosis difficult, it was confirmed to be a rare variant of anti-GQ1b antibody syndrome showing corticobulbar and corticospinal tract involvement. The patient showed excellent recovery after dysphagia treatment.

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A Case of Severe Dysphagia after Aesthetic Two-Jaw Surgery

Yeon Hee IM ; Soo Ah SON ; Sung Joon PARK ; Young Hak PARK

Journal of the Korean Dysphagia Society.2021;11(1):67-71. doi:10.34160/jkds.2021.11.1.009

This study reports a case who presented with swallowing difficulty after orthognathic surgery. A female patient, who had undergone orthognathic surgery for esthetic purpose, presented with dysphagia. Administration of botulinum toxin injection to the cricopharyngeus muscle did not relieve or improve the severe dysphagia. The patient required nasogastric tube feeding for about three months. Swallowing ability was recovered after daily rehabilitation therapy and prescribing pyridostigmine. Injuries to the suprahyoid muscles (involved in laryngeal elevation during the pharyngeal phase of swallowing) during orthognathic surgery, and the inadvertent dissemination of inadequately injected botulinum toxin to adjacent muscles, are possible mechanisms of the severe dysphagia experienced by this patient. The authors also reviewed literature on the prevention and management of dysphagia following the orthognathic surgery.

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Usefulness of Maximal Expiratory Pressure in Evaluating Dysphagia after Ischemic Stroke

Bo Seong JANG ; Ho Joong JEONG ; Han Eum CHOI ; Jae Hyun LEE ; Young Joo SIM ; Ghi Chan KIM

Journal of the Korean Dysphagia Society.2021;11(1):59-66. doi:10.34160/jkds.2021.11.1.008

Objective: We investigated the usefulness of maximal expiratory pressure (MEP) in evaluating dysphagia subsequent to ischemic stroke. Methods: This study included patients with ischemic stroke who underwent MEP testing and videofluoroscopic swallowing study (VFSS), from October 2016 to February 2020. The VFSS findings were interpreted using the penetrationaspiration scale (PAS) and functional dysphagia scale (FDS). Patients were stratified into the non-aspiration (n=59) and aspiration (n=47) groups. Partial correlation analysis among MEP, PAS, and FDS was performed after adjusting for age. Binary logistic regression using PAS was conducted to investigate the risk factors predisposing patients to inclusion in the aspiration group. Multiple linear regression using FDS was conducted to investigate the risk factors according to dysphagia severity. Receiver operating characteristic (ROC) curve analysis was applied to investigate factors which could be useful for detecting aspiration. Results: Student’s t-test revealed a significant difference in MEP between the non-aspiration and aspiration groups.MEP showed a positive correlation with PAS and FDS. MEP was also determined to be a risk factor for inclusion into the aspiration group, and a risk factor according to the severity of dysphagia. In the ROC curve analysis, MEP showed good diagnostic properties to help classify patients with aspiration. Conclusion Our results indicate that swallowing assessment can predict and help prevent aspiration pneumonia in patients with ischemic stroke. In the present study, MEP showed significant association with aspiration and the severity of dysphagia. Thus, determining the MEP during swallowing assessment in patients with ischemic stroke is potentially a useful parameter to predict dysphagia.

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Comparison of Videofluoroscopic Swallowing Study in Patients with Stroke-Associated Pneumonia

Jae Sam SEO ; Kyo Hun KU ; Young Sook PARK

Journal of the Korean Dysphagia Society.2021;11(1):52-58. doi:10.34160/jkds.2021.11.1.007

Objective: To compare the findings of videofluoroscopic swallowing study (VFSS) in patients with stroke-associated pneumonia (SAP). Methods: Between January 2015 and June 2019, 1245 patients diagnosed with pneumonia underwent VFSS examination. Data were collected through retrospective chart reviews. Depending on the diagnosis, 378 post-stroke patients identified were classified into two groups: 327 non-aspiration pneumonia (non-AP) and 51 aspiration pneumonia (AP). Aspiration pneumonia was diagnosed both clinically and radiologically. VFSS results included 11 items of functional dysphagia scoring (FDS) and 8 points of penetration-aspiration scale (PAS) that analyze the swallowing function by anatomical site. Results: Based on the FDS score, the AP group showed significantly higher values in residue in pyriform sinuses (P= 0.01), as compared to the non-AP group. There was a significant difference in the PAS score between both groups (P＜0.001). Conclusion Based on the FDS results, AP in SAP is associated with residue in piriform sinuses. VFSS tests therefore have the potential to be clinically applied to predict the occurrence of aspiration pneumonia in stroke patients.

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Effectiveness of Formal Dysphagia Screening for Stroke Patients

Mi Ran YOO ; Yoon Mok CHUN ; Kyoung Hyo CHOI ; Sun Uck KWON ; Eun-Jae LEE

Journal of the Korean Dysphagia Society.2021;11(1):43-51. doi:10.34160/jkds.2021.11.1.006

Objective: Early identification of dysphagia after stroke helps in preventing aspiration pneumonia. However, data are limited regarding the effectiveness of formal dysphagia screening for reducing the risk of aspiration pneumonia.The current study evaluates the effectiveness of formal dysphagia screening in stroke patients, to prevent future episodes of aspiration pneumonia. Methods: The stroke registry of a tertiary hospital was retrospectively reviewed. We compared clinical variables and the incidence of aspiration pneumonia of patients hospitalized between 2014 and 2015 after formal screening was implemented, and patients hospitalized in 2011 when no established dysphagia screening protocol was in place.Additionally, we identified the incidence of pneumonia according to stroke severity, and evaluated the association with results obtained for incidence of pneumonia and dysphagia screening. Results: A total of 2,902 patients were identified to have suffered acute stroke (2,018 who underwent formal dysphagia screening; 884 without screening). Patients with formal dysphagia screening developed pneumonia less frequently than patients not administered screening (1.3% with formal screening vs. 3.4% no formal screening, P＜0.001).Pneumonia was significantly lower in patients with moderate and severe stroke who underwent formal dysphagia screening. Furthermore, failure of the dysphagia screening test, presentation with severe dysarthria, and conditions where dysarthria could not be evaluated, were independent predictors of pneumonia among patients who underwent formal screening. Conclusion Our findings demonstrate the association of formal dysphagia screening with reduced risk of poststroke aspiration pneumonia, and indicates the efficacy of the procedure in identifying patients at higher risk of contracting pneumonia.

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Concordance between Oropharyngeal Flora and Peristomal Wound Culture Bacteria Following Percutaneous Endoscopic Gastrostomy: A Prospective Cohort Study

Da Hwi JUNG ; Dong Hoon BAEK ; Jin A YOON ; Sang Hun KIM ; Byeong Ju LEE ; Mi Kyung CHO ; Yong Beom SHIN

Journal of the Korean Dysphagia Society.2021;11(1):35-42. doi:10.34160/jkds.2021.11.1.005

Objective: To examine the concordance between the oropharyngeal flora and peristomal wound culture bacteria following percutaneous endoscopic gastrostomy (PEG) placement. Methods: Cultures of oropharyngeal flora before PEG placement and peristomal wound cultures after PEG placement were examined prospectively in patients who underwent PEG between June 1, 2017, and June 1, 2019, at a local rehabilitation center. Microorganisms in the oropharyngeal flora and peristomal wound culture were identified, and the relationship between them was examined. The risk factors that may increase the PEG infection rate were also examined. Results: The predominant bacterium identified in the oropharyngeal flora and peristomal wounds in patients who required PEG was Pseudomonas aeruginosa. The concordance between the oropharyngeal flora and peristomal wound culture bacteria in patients with PEG infections was confirmed. Different oropharyngeal flora was observed in patients with a prolonged hospital stay compared to that of healthy adults. The concordance between the oropharyngeal flora and peristomal wounds was also identified with a high prevalence of gram-negative bacilli. There was no potential risk factor, such as comorbidities or length of hospitalization of patients associated with PEG infections. Conclusion Because the oropharyngeal flora showed concordance with the bacteria found in the PEG stoma site, management of the oropharyngeal flora before PEG insertion should be considered for patients with dysphagia.

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Relationship between Swallowing Function, Diet Level and Pulmonary Function in Post-Stroke Patients

Myungeun YOO ; Hyo Jeong LEE ; Eu Jeong KO ; Jinyoung PARK ; Yoon Ghil PARK

Journal of the Korean Dysphagia Society.2021;11(1):25-34. doi:10.34160/jkds.2021.11.1.004

Objective: To identify the relationship between dysphagia, dietary level, and pulmonary function in post-stroke patients. Methods: Thirty-six post-stroke patients with dysphagia, who were hospitalized from June 2017 to October 2017 in the Department of Rehabilitation Medicine at a tertiary hospital, were analyzed retrospectively. The video-fluoroscopic swallowing study (VFSS) and videofluoroscopic dysphagia scale (VDS) were used to assess dysphagia. The vital capacity (VC) and peak cough flow (PCF) were used to assess the pulmonary function. Upon admission, the patients were divided into three groups according to their dietary level (tube feeding, dysphagia diet, and general diet). The correlation between dysphagia and pulmonary function was analyzed using an independent t-test test with the optimal points, and the relationship between the diet level and pulmonary function was evaluated using a one-way analysis of the variance. Results: Significant correlations between the pulmonary function and sub-items of VDS were found in “oral transit time” with VC, “vallecullar residue” and “aspiration” with PCF, and “triggering of pharyngeal swallow”, “VDS total score” with VC and PCF. The dietary levels upon admission had a significant correlation with VC and PCF. The VC among groups divided according to three diet levels showed statistically significant differences. Conclusion This study revealed the relationship between the pulmonary function and dysphagia in post-stroke patients. Moreover, the pulmonary function correlated with dietary level, even though it was not confirmed that it affected dietary levels. The clinical importance of the pulmonary function in post-stroke patients with dysphagia should be emphasized. In addition, a large-scale study is needed to determine the correlation between the pulmonary function and swallowing difficulty

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Designed Meal Development and Sensory Evaluation for Dysphagia Patients

Kui-Jeong CHOI ; Young-Sook PARK ; Min Yong SEONG ; Byung-Mo OH ; Weon-Sun SHIN

Journal of the Korean Dysphagia Society.2021;11(1):15-24. doi:10.34160/jkds.2021.11.1.003

Objective: Thickening agents used in dysphagia diets to adjust the viscosity of foods adversely affect the inherent food flavors and colors. Chopped and ground foods have unfamiliar flavors, colors and textures, causing a loss of appetite. Therefore, this study aimed to develop a savory and easy-to-make dysphagia diet without changing the appearance and taste of foods, and evaluate the suitability of the newly developed diet for patients with dysphagia. Methods: Twenty participants aged 55-85 years (8 patients with dysphagia and 12 healthy elderly) were recruited.The diet consisted of fried rice, hamburger steak, and soybean paste soup, where the solid foods were categorized as International Dysphagia Diet Standardisation Initiative (IDDSI) Level 5 (Minced and Moist), and the liquid foods were categorized as IDDSI Level 2 (Mildly Thick). To develop the dysphagia diet, textural modifications to the ingredients and viscosity adjustments were applied. A sensory evaluation was conducted by the panel to measure the extent of chewing, swallowing, adhesiveness, choking, and overall flavor and preference. Results: No significant differences in textural properties, such as chewing, swallowing, adhesiveness and choking, were observed between the control and patient groups, but the flavor and preferences in the patient group were statistically significant. Conclusion The modified and newly designed dysphagia foods positively impacted easy swallowing for patients with dysphagia. Therefore, customized dysphagia foods should be considered in terms of flavor-enhancement to provide tailored diets for patients with dysphagia.

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