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Dysphagia as the First Symptom of Hyperthyroidism without Goiter: A Case Report

Jong Dae EUN ; Yun-Hee KIM ; Won Hyuk CHANG

Journal of the Korean Dysphagia Society.2020;10(1):138-142. doi:10.34160/jkds.2020.10.1.018

Hyperthyroidism is a rare cause of dysphagia. We report a case of dysphagia as the first symptom of hyperthyroidism in a patient who improved with antithyroid agents and swallowing rehabilitation. An 81-year-old man was diagnosed with Graves’ disease after being hospitalized for recurrent aspiration symptoms that included cough and sputum for two months. The patient was given methimazole, propranolol, and Lugol solution as well as conventional swallowing rehabilitation for 60 minutes a day. Two weeks after initiation of treatment, the patient’s thyroid function tests saw improvement. He showed significant improvement in dysphagia after 3 weeks of treatment.Persisting improvement in swallowing was also found at 6 months post-treatment. Dysphagia may be the first symptom of hyperthyroidism in elderly patients, and physicians should consider performing thyroid function tests for evaluating such patients.

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Esophagostomy as an Alternative to Gastrostomy for Dysphagia in Muscular Dystrophy: A Case Report

Jin Seok BAE ; Jong Keun KIM ; Jong Youb LIM ; Kang Jae JUNG ; Hyo Sik PARK

Journal of the Korean Dysphagia Society.2020;10(1):134-137. doi:10.34160/jkds.2020.10.1.017

Many people with muscular dystrophy develop dysphagia that can result in an inability to use the oral route in severe cases. In such cases, an alternative feeding method is selected, including a nasogastric tube or a gastrostomy.This case report describes a 40-year-old man with muscular dystrophy who was managed for swallowing difficulty and respiratory failure. Oromotor muscle weakness caused prolonged mealtimes, difficulty with swallowing a solidform diet, aspiration signs, and weight loss. Consequently, an alternative feeding method was required. An abdominal radiograph showed massive aerophagia, and the transverse colon was located over the stomach. As a result, the colon interfered with the puncture route, which could lead to colon perforation. Therefore, cervical esophagostomy was selected, where the patient obtained nutrition through a cervical esophagostomy tube. This case showed that when gastrostomy cannot be performed due to aerophagia, cervical esophagostomy can successfully support nutrition for the mid to long-term in muscular dystrophy patients.

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Tracheoesophageal Fistula by Chemoradiotherapy after a Total Laryngectomy in a Laryngeal Cancer Patient: A Case Report

Ji Hye KANG ; Inn-Chul NAM ; Min-Wook KIM

Journal of the Korean Dysphagia Society.2020;10(1):130-133. doi:10.34160/jkds.2020.10.1.016

An acquired tracheoesophageal fistula (TEF) is a rare complication that can occur in the treatment of laryngeal cancer. Explosive coughing from the tracheostomy-opening site after swallowing is a warning sign of the TEF. A 68-year old male laryngeal cancer patient showed delayed TEF after chemoradiotherapy with a total laryngectomy.The clinicians carrying out a videofluoroscopic swallowing study should be familiar with the total laryngectomy state, as well as the findings and initial general management of TEF. This report discusses the pathophysiology and management of TEF and the needs for dysphagia care team after chemoradiation in laryngeal cancer patients.

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Improvement of Dysphagia in Traumatic Neurovascular Compression: A Case Report and Collective Review

Yong Kyun KIM ; Yun Jung LEE ; Yong Seob JO ; Jung Hyun CHA

Journal of the Korean Dysphagia Society.2020;10(1):123-129. doi:10.34160/jkds.2020.10.1.015

Dysphagia is a relatively rare symptom of neurovascular compression of the lower cranial nerve (CN). Many case reviews of neurovascular compression required surgical treatment to improve the neurological symptoms. This report presents a 75-year-old female patient who complained of dysphagia due to neurovascular compression of CNs IX-XI at the left side after the onset period. The symptom was improved by treating with balloon swallowing rehabilitation (BSR). In a video fluoroscopic swallowing study (VFSS), no significant manifestations were observed in the oral phase. On the other hand, profuse post-swallow residue decreased pharyngeal propulsion were observed without aspiration or penetration during the semisolid portion of the swallowing test. To reduce the pharyngeal remnant and improve pharyngeal propulsion, the BSR protocol was performed and the patient recovered quickly.Follow-up VFSS showed improvement in the post-swallow residue from 42.6 to 7.3%. After discharge, the patient could resume a normal diet without complications. Based on this observed result, it is advantageous to consider the option of a prescribed rehabilitation program over surgical treatment.

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Characteristics and Risk Factors of Aspiration in Lateral Medullary Infarction

Ju Sun KIM ; Hyun Jung KIM ; Jun Yup KIM ; Hyo Seon CHOI ; Juntaek HONG ; Deog Young KIM

Journal of the Korean Dysphagia Society.2020;10(1):113-122. doi:10.34160/jkds.2020.10.1.014

Objective: To evaluate the characteristics of dysphagia and identify the risk factors of bolus aspiration in patients presenting with pure lateral medullary infarction (LMI). Methods: Between January 2014 and January 2019, 51 post-stroke patients with LMI who underwent a videofluoroscopic swallowing study (VFSS) were enrolled retrospectively, and their medical records and brain magnetic resonance imaging results were reviewed. The VFSS results were evaluated to analyze the swallowing function using the penetration-aspiration scale, functional dysphagia scale, and imaging analysis software. Results: Bolus aspiration was detected in 21 patients (41.2%). The common abnormal VFSS findings were residue in valleculae (74.5%), delayed triggering of pharyngeal swallow (72.5%), residue in pyriform sinuses (62.7%), delayed pharyngeal transit time (56.9%), reduced laryngeal elevation (51.0%), and coating of the pharyngeal wall (49.0%). The incidence of aspiration was significantly higher in the typical lesions (including the diagonal band-shaped lesions) and the large type lesions extending ventrally or dorsally, as compared to other lesion types (P＜0.05). Logistic regression analyses revealed that the residue in pyriform sinuses is a significant independent risk factor of aspiration in the puree trial, and prolonged pharyngeal delay time (PDT) and residue in valleculae are significant risk factors in the thin liquid trial (P＜0.05). Conclusion Considering all clinical factors, lesion locations, and swallowing processes, results of the current study indicate that residue in pyriform sinuses is an independent risk factor of aspiration in the swallowing puree technique, whereas prolonged PDT and residue in valleculae are independent risk factors of aspiration in the swallowing liquid technique.

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High Resolution Manometry versus Video Fluorography for Evaluating Dysphagia in Patients with Inflammatory Myopathy: A Pilot Study

Minji JUNG ; Kyoung Hyo CHOI ; Kyeong Joo SONG ; Kee Wook JEONG ; Yong-Gil KIM

Journal of the Korean Dysphagia Society.2020;10(1):107-112. doi:10.34160/jkds.2020.10.1.013

Objective: Dysphagia has been reported to occur in patients with inflammatory myopathy (IM). Although high-resolution impedance manometry (HRIM) provides precise information regarding the pharyngeal pressure, it has not yet been used for assessing dysphagia in routine clinical practice. This study determined whether the results of HRIM for evaluating deglutition disorders in patients with IM could reflect an abnormality that can’t be identified by a video fluoroscopic swallowing study (VFSS). Methods: We reviewed both VFSS and HRIM results of nine patients with IM, four of whom presented with globus sensation. Results: Cricopharyngeal muscle dysfunction was noted in all four patients with globus sensation, and the upper esophageal sphincter residual pressure (UESRP) was higher (≥8 mmHg) in the patients with pharyngeal residue.Using VFSS and HRIM, we demonstrated that dysphagia in patients with IM may arise owing to failed relaxation of UES or decreased hyolaryngeal excursion. Conclusion In conclusion, UES-RP values of ≥8 mmHg indicate the presence of pharyngeal residue and globus sensation in patients with IM. HRIM provided a comprehensive assessment of the mechanisms of dysphagia, and HRIM facilitated recognizing subtle abnormalities in pharyngeal contraction and UES function. HRIM can overcome the limitations of VFSS by allowing clinicians to perform objective measurements in patients with IM.

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Prevalence and Medical Cost under Malnutrition in Dysphagia Patients of Korea: Based on Health Insurance Review & Assessment Service (HIRA) Data

Bora LEE ; Hee-Sook LIM

Journal of the Korean Dysphagia Society.2020;10(1):97-106. doi:10.34160/jkds.2020.10.1.012

Objective: This study aimed to analyze the prevalence and nutritional status of patients with dysphagia using the National Health Insurance Claim database collected from all Koreans. Methods: According to the claim data from the National Health Insurance Service from 2007 to 2017, we calculated the prevalence, comorbidity, and direct medical costs of dysphagia patients. We analyzed the difference in medical costs according to the malnutrition rate and presence of malnutrition. Results: The prevalence of dysphagia was 635.4 per 100,000 population in 2007 but increased to 1031.6 in 2017. The proportions of type insurance showed an increasing trend in both health insurance and national free medical care, while nursing hospitals showed a significant increase of 8.46%. Esophageal and gastrointestinal disorders accounted for the highest number of diseases with dysphagia. The average medical expense per person for dysphagia was 11,984,632 Korea Won (KRW), and the average length of hospital stay was 154.1 days. The malnutrition rate of patients with dysphagia was 686.8 out of 100,000 people in 2007 to 362.9 out of 100,000 people in 2017. The malnourished group had 70.7 more inpatient hospital stays and nine more outpatient visits than the non-malnourished group. Conclusion The proportion of nursing hospitals and medical expenses increased significantly in the number of patients with dysphagia, and the length of hospital stay and medical costs were higher with malnutrition. As incidence of dysphagia patients may increase due to aging, active management of dysphagia is required to improve the patient’s prognosis and quality of life.

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Association of Tongue Pressure with Swallowing Function and Quality of Life in Parkinson’s Disease

JaYoung KIM ; Kyoung Hyo CHOI ; Young-Jin SONG ; Sun Ju CHUNG ; Kye Won PARK ; Kyeong Joo SONG ; Woo Chul SON ; Hye Joon AHN

Journal of the Korean Dysphagia Society.2020;10(1):92-96. doi:10.34160/jkds.2020.10.1.011

Objective: The purpose of this study was to verify the hypothesis, by performing objective measurements, that tongue pressure will have an association with swallowing function in patients with Parkinson’s disease. It was also of interest whether measures of lingual function were consistent with reports of swallowing related quality of life. Methods: The subjects were 18 patients with Parkinson’s disease. Their tongue pressure was examined by using an Iowa oral performance instrument (IOPI). They all underwent video fluoroscopic swallowing study (VFSS) and they completed a Korean swallowing-quality of life questionnaire (K-SWAL-QOL). Tongue pressures were measured in the anterior (MTPa: maximal tongue pressure anterior) and posterior (MTPp: maximal tongue pressure posterior). The cutoff value of MTP was 34 kPa. Results: The average of tongue pressure was decreased in both anterior (MTPa=27.79±13.44 kPa) and posterior (MTPp=19.20±8.88 kPa), and MTPp of all the subjects was less than 34 kPa. For the MTPa, 11 patients were under 34 kPa (abnormal group) and 7 patients were above 34 kPa (normal group). The oral transit time (OTT) of the abnormal MTPa group was significantly delayed more than that of the normal group (P=0.006). On the correlation analysis, the MTPa and OTT, MTPa and penetration aspiration scale (PAS), MTPp and PAS showed significant negative correlations with each other. The MTP and the social, sleep and fatigue subscores of K-SWAL-QOL showed significant positive correlations. Conclusion In patients with Parkinson’s disease, lower tongue pressure was related to delayed oral transit time and a higher aspiration tendency. We expect the clinical usage of the easily measured tongue pressure to predict the swallowing function and help plan the correct treatment.

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Risk Factor Analysis of Dysphagia after Oncological Surgery for Patients with Head and Neck Cancer Using a Modified Barium Swallowing Study

Sung Joon PARK ; Haram KANG ; Young Hak PARK

Journal of the Korean Dysphagia Society.2020;10(1):79-91. doi:10.34160/jkds.2020.10.1.010

Objective: This study evaluated the risk factors for tube feeding dependency of the patients with head and neck squamous cell carcinoma (HNSCC) who underwent an operation with curative intent. Methods: The medical records of patients with HNSCC who underwent operation with curative intent and who also had postoperative MBSS (modified barium swallow study) performed at a single institution were retrospectively reviewed between January 2013 and December 2018. The clinical and oncological characteristics along with the MBS findings and questionnaire results were retrieved. These were used to analyze the potential risk factors for tube feeding dependency after surgery. Univariate analysis of each factor was conducted and the odds ratios were calculated. Additionally, multivariate analysis was performed for the significant factors found on the univariate analysis. Results: 60 HNSCC patients (male:female=54:6) with four different primary sites of cancer and who had a mean age of 65.90±11.09 years-old were included in this study. 41 (68.3%) patients were T1-T2, 33 (55%) patients were N+, and 36 (60%) patients were advanced staged (III and IV). 30 (50%) patients received reconstruction with various flaps and 55 (91.7%) patients received neck dissection. Univariate analysis showed a prior history of radiation based therapy and chemoradiation along with silent aspiration, aspiration, pyriform sinus residue, pharyngeal weakness, and high PAS and SPS scores based on MBS showed a significant risk for feeding tube dependency. Multivariate analysis using these factors showed that only the prior history of radiation based therapy and a high SPS score were significant risk factors for feeding tube dependency. Conclusion Our study showed a 21.7% rate of feeding tube dependency after surgical treatment of HNSCC. A prior history of radiation based treatment and a higher swallowing performance scale score were the significant risk factors for tube feeding dependency.

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Correlation between Dysarthria and Aspiration in Patients with Stroke

Eun-Ho YU ; Myung Hoon MOON ; Ji Hong MIN ; Hye-Kyung KIM ; Yong-Il SHIN ; Hyun-Yoon KO ; So Jung KIM ; Sung-Hwa KO

Journal of the Korean Dysphagia Society.2020;10(1):72-78. doi:10.34160/jkds.2020.10.1.009

Objective: This study examined the correlation between dysarthria and aspiration to determine if dysarthria can predict aspiration in stroke patients. Methods: The medical records of 176 patients with first stroke, who underwent a videofluoroscopic swallowing study (VFSS) and Urimal test of articulation and phonology (U-TAP) at the same time between January 2012 and December 2015 in the authors’ hospital, were reviewed retrospectively. The correlation between the penetration aspiration scale (PAS) score and U-TAP score was analyzed in all patients. The mean PAS score and frequency of each PAS score in the dysarthria group and non-dysarthria group were compared. In addition, the aspiration was analyzed based on the severity of dysarthria in the dysphagia group. All statistical analyses were performed using SPSS software. Results: The correlation between the PAS score and U-TAP score was not statistically significant in all the subjects.The mean PAS score was 3.46±5.52 and 3.07±5.49 in the dysphagia and non-dysphagia group, respectively. The mean PAS score of the dysphagia group was higher than that of the non-dysphagia group. On the other hand, it was not statistically significant. In addition, there was no significant difference in the frequency of the PAS scores between the two groups. The aspiration was compared with the severity of dysarthria according to the U-TAP score; there was no statistically significant difference. Conclusion No correlation was observed between dysarthria and aspiration in stroke patients. In addition, there was no difference in the frequency of aspiration with or without dysarthria. According to the results of this study, aspiration cannot be predicted by dysarthria in stroke patients. Therefore, each diagnostic test and assessment should be performed for each symptom.

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