Article

Pharyngeal sensation and gag reflex in healthy adults

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Abstract

The gag reflex is often used in the assessment of swallowing, yet its absence does not predict aspiration in acute stroke. Disordered pharyngeal sensation has been found to be a sensitive predictor. The occurrence of gag reflex and pharyngeal sensation in healthy people is unknown. We studied these tests in 140 healthy subjects (half elderly and half young). Gag reflex was absent in 37% of subjects whereas pharyngeal sensation was absent in only 1. The results largely explain the low predictive value of gag reflex in the assessment of aspiration in acute stroke. Testing pharyngeal sensation would be more likely to be useful in these circumstances.

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... Studies assessing stroke patients ability to swallow during the first few days and weeks following stroke have not confirmed this evidence (Logemann, 1983;Massey, 1988 Stanners, 1993;Bleach, 1993). More recently work done by Davies et al (1995) demonstrated that the gag reflex was absent in half of fit elderly people and a third of young volunteers despite them all having a normal and safe swallow. Despite this evidence many doctors in training and nursing staff rely on the gag reflex as a proxy for a safe swallow (Smithard et al., 1996). ...
... This was not supported in a study with a more heterogenous population of stroke patients (Homer et al., 1988). The gag reflex is there to prevent material entering the pharynx and has a role completely different to that of swallowing (Logemann, 1988), and on its own an impaired pharyngeal gag does not indicate the inability to swallow (Davies et al, 1995). Recently Kidd et al. (1993) have suggested that the absence of pharyngeal sensation predicts aspiration with a sensitivity of 100%. ...
... The presence of the gag reflex seems to be the most common proxy for a safe swallow, yet these results and those of others Massey, 1988, 1991) suggest that it is of no value in the assessment of dysphagia. This is reinforced by recent work showing that many healthy elderly and a significant minority of young people have an absent gag (Davies et al., 1995). ...
Thesis
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Published data suggests that the bedside assessment of swallowing has limited usefulness. There is a paucity of information on the natural history of dysphagia following stroke and the relationship of dysphagia to outcome. This thesis examines the above areas. One hundred and twenty one consecutive acute stroke patients have been prospectively studied. Their swallowing was assessed, using standardised proformas, by both a doctor and a speech and language therapist, nutritional status was also documented (anthropometric and haematological parameters). Assessments were repeated at 7, 28 and 180 days. Where feasible a videofluoroscopy was conducted within 3 days of admission and at day 28. A CT scan was also performed. Outcome measures were the presence of chest infection, mortality, length of stay, disability and institutionalisation. On admission, 31% (32/104) of those assessed by the speech and language therapist, and 50% (61/121) by the doctor had dysphagia, 21% (20/94) were aspirating on videofluoroscopy. Detailed assessment by the speech and language therapist gave a sensitivity of 47%, specificity of 86%, positive predictive value of 50% and a negative predictive value of 85% for aspiration. Multiple logistic regression analysis identified a weak voluntary cough, coughing on 5 mis of water and any alteration of conscious level as the best predictors of aspiration. Patients with dysphagia had a higher incidence of chest infection (p[less-than]0.01), poor nutritional state (p=0.038), mortality (p=0.022), disability (p=0.02), length of stay (p[less-than] 0.001), and institutionalisation (p[less-than]0.05). Dysphagia, but not aspiration, was an independent predictor for mortality and chest infection. Dysphagia was still present in 27% (28/110) at day 7 and 11% (8/73) at six months, 3% (2/73) had developed dysphagia. Twelve patients were aspirating on videofluoroscopy at day 28. In conclusion, dysphagia is common following stroke, may be transient, persist or develop at a later date. The poor reliability of the bedside assessment is confirmed. Dysphagia at the time of stroke is associated with a worse outcome, but the routine use of videofluoroscopy is questioned.
... 4 Bulantı-kusma refleksinin prevalansı kesin olarak bilinmemekle beraber, bu refleksle ilgili Davies ve ark.nın yaptığı bir çalışmada, insanların yaklaşık %74'ünde farklı şiddette bulantı-kusma refleksi görüldüğü bildirilmiştir. 5 Bulantı-kusma refleksi, hem erişkinlerde hem de çocuklarda görülebilmektedir. Pediatrik yaş grubunda yapılan bir çalışmada, 4-12 yaş aralığındaki çocukların %30'unda çeşitli uyaranlara maruz kalmaları sonucu bulantı-kusma refleksi oluştuğu bildirilmiş ve küçük yaştaki çocukların, büyük yaştaki çocuklara göre daha fazla oranda bulantı-kusma refleksine sahip olduğu vurgulanmıştır. ...
... 9,10 Bulantı ve kusma refleksine neden olan etiyolojik faktörler; anatomik, tıbbi, psikolojik ve iyatrojenik faktörler olarak sınıflandırılabilir. 3 Bulantı ve kusma refleksinin anatomik nedenleri arasında, kraniyal sinirlerin inervasyon farkları, maksiller kemikte oluşan rezorpsiyon miktarı, yumuşak damak anatomisindeki farklar sayılabilir. 5,[9][10][11][12][13] Anatomik faktörler, cinsiyetler arasında da farklılık gösterebilmektedir. Özellikle erkek hastalarda, ağız boşluğu ve faringeal bölgenin arka kısmının stimülasyona daha duyarlı olması nedeniyle daha sık bulantı ve kusma refleksi görüldüğü bildirilmiştir. ...
... Third, the ecological meaning of the whole movement sequence might determine affective consequences, a prediction that we favored. Applied to oral movements, a sequence of first-inward-then-outward (in-out in the following) would be similar to habituated aversive responses (Davies, Stone, Kidd, & MacMahon, 1995;Rozin, 1999;Teff, 2000): it occurs when we have a sip from a liquid or a bite from a solid, realize that it is spoiled, and then spit it out. In contrast, the reversed sequence, an outward-then-inward pattern (out-in in the following) rather resembles the kinematics when an object that is already in the rear of the mouth is moved forwards and backwards again, such as during sucking a candy. ...
... We attribute this effect to an association between in-out and aversive disgust reflexes when something aversive enters the mouth and is then expelled (e.g., Davies et al., 1995); and an association between out-in and oral kinematics during consuming food and insalivating the food bolus (Duffy, 2007;Goyal & Mashimo, 2006), which are positive and consumptionrelated. The lower preference for in-out than for out-in occurred in both English and German samples, without participants showing awareness of the underlying consonantal structure, and cannot be explained by phonotactic frequencies in the languages themselves (see above). ...
Article
The affective consequences of sequential approach-avoidance movements in the mouth were investigated. Participants (total N = 872) received words for which consonantal stricture spots either wandered first-inward-then-outward (e.g., FOLOKOLOF; approach-avoidance) or first-outward-then-inward (e.g., KOLOFOLOK; avoidance-approach) in the mouth. In a pilot study, it was established that first-inward-then-outward (first-outward-then-inward) is associated with negative disgust (positive ingestion) reactions (Experiment 1). Approach-avoidance sequences were preferred less than avoidance-approach sequences (Experiments 2a-3b); and this effect disappeared under oral motor-interference (Experiment 4). Experiment 5 provides evidence that a mere recency effect is an unlikely explanation for these effects. Thus, sequentially executed oral approach and avoidance movements do not cancel each other out but jointly influence resulting affective responses.
... The other possible explanation is that this patient lacks a gag reflex with an intact reflexive pharyngeal swallow. A high incidence rate (37%) related to an absent gag reflex has been reported among patients, although they have an intact pharyngeal sensation [12]. One can infer that patients may have normal muscle function for swallowing, which is independent from the muscles controlling the gag reflex. ...
... One can infer that patients may have normal muscle function for swallowing, which is independent from the muscles controlling the gag reflex. Interestingly, the swallowing reflex also acts as protective mechanism for the upper respiratory system, forcing the glottis to close and clearing the pharynx from residual food substances [12]. Our patient did not undergo further investigation regarding her pharyngeal sensation. ...
Article
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Introduction Dislodgment of nasopharyngeal temperature probes and/or unretrieved device fragments (UDFs) or gossypibome at a patient’s hypopharynx is rare complication after orthognathic surgery that may occur as a result of surgical manipulation or may be a consequence of factors related to the insertion and handling of the probe after extubation. However, the exact mechanism of this complication is unknown. To the best of our knowledge, this is the 1st reported case of a missing temperature probe after orthognathic surgery. Case presentation We report the case of a patient who suffered from dislodgment of a 12-cm temperature probe after orthognathic surgery. The surgery was uneventful. At the end of the surgery, the probe was believed to have been completely removed from the nasal cavity. The nasopharyngeal cavity was visually inspected while the patient was still under anaesthesia and the trachea was still intubated. Extubation was successful, and the patient was moved to the recovery area. The patient was discharged from the hospital one day after resuming an oral fluid diet. At the follow-up visit on the 4th postoperative day, the patient presented with mild symptoms of a sore throat and cough. At the follow-up visit in the 3rd postoperative week, the patient reported one episode of vomiting and severe coughing, and the patient ultimately retrieved the 12-cm temperature probe from her mouth. Discussion After conducting a systematic literature review, we discuss surgical cases involving UDFs or gossypiboma. We also describe changes in our clinical practice after this event, and we envision that these modifications will have a positive influence on patient care. We believe that alternative routes for inserting temperature probes with covers would be suitable for orthognathic surgery. Conclusion Vigilance should be maintained during patient extubation by both teams (surgeons and anaesthetists) to assure that part of the probe always remains visible outside the oral/nasal cavity as well as complete removal of the device to avoid this life-threating complication.
... Also, Baseline preoperative gag reflex was not evaluated, as Patients who did not have gag reflex following tonsillectomy might have no gag reflex preoperatively. It has been found that the gag reflex could be not present in the normal population [22]. ...
Article
The glossopharyngeal nerve block (GNB) was evaluated for pain control together with the magnitude of obtunded gag reflex as a useful clinical sign of GNB. Methods 400 patients scheduled for oropharyngeal surgery were randomly allocated into 2 groups (200 patients in each group), Group1 patients received bilateral GNB with 0.125% bupivacaine, 0.5 xylocaine, and 4 mg dexamethasone, while Group 2 patients were enrolled as a control group. Throat pain was evaluated using the visual analog scale at 0.5, 8, and 24 h after surgery, and the degree of gag reflex response was evaluated at the same time points. Results Postoperative pain scores at rest and during swallowing were significantly lower in Group 1 versus Group 2. The analgesic efficacy of GNB was intensely interrelated with the magnitude of the obtunded gag reflex (P 0.01). Conclusions GNB is beneficial for pain control in oropharyngeal surgery. An obtunded gag reflex could be a useful clinical sign for a successful GNB analgesic outcome.
... This finding indicates that a unilaterally impaired gag reflex mechanism also satisfactorily enables the patient to withstand the intraoral stimuli caused by the OE tube. Although a gag reflex is often absent in healthy adults [16], an absent gag reflex is 10 times more frequent in dysphagic patients with an acute stroke, and is associated with a need for tube feeding [17]. It is reported to be an independent predictor of non-oral feeding in the subacute phase (at 6 weeks from onset) [18]. ...
Article
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Objective To identify possible clinical predictors of intermittent oro-esophageal (OE) tube feeding success, and evaluate the clinical factors associated with OE tube treatment. Methods A total of 135 dysphagic patients were reviewed, who received OE tube treatment and were hospitalized in the department of rehabilitation medicine between January 2005 and December 2014. The 76 eligible cases enrolled were divided into two groups, based on the OE tube training success. Clinical factors assessed included age, cause of brain lesion, gag reflex, cognitive function and reasons for OE tube training failure. Results Of the 76 cases enrolled, 56 study patients were assigned to the success group, with the remaining 20 in the failure group. There were significant differences between these two groups in terms of age, gag reflex, ability to follow commands, and the score of Korean version of Mini-Mental Status Examination (K-MMSE). Location of the brain lesion showed a borderline significance. Multivariable analysis using logistic regression revealed that age, cause of brain lesion, gag reflex, and K-MMSE were the main predictors of OE tube training success. Conclusion A younger age, impaired gag reflex and higher cognitive function (specifically a K-MMSE score ≥19.5) are associated with an increased probability of OE tube training success in dysphagic patients.
... Touching oropharyngeal structures with a cotton swab or with a needle is a widely used but not quantifiable clinical routine. Nevertheless, these methods were solely used to describe age-related changes in oropharyngeal sensitivity in the past 34,35 . One semiquantifiable method is the use of monofilaments 36 . ...
Article
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Oropharyngeal sensitivity plays a vital role in the initiation of the swallowing reflex and is thought to decline as part of the aging-process. Taste and smell functions appear to decline with age as well. The aim of our study was to generate data of oral sensitivity in healthy participants for future studies and to analyse age-related changes and their interdependence by measuring oral sensitivity, taste, and smell function. The experiment involved 30 participants younger than and 30 participants older than 60. Sensitivity threshold as a surrogate of oral sensitivity was measured at the anterior faucial pillar by electrical stimulation using commercially available pudendal electrode mounted on a gloved finger. Smell and taste were evaluated using commercially available test kits. Mean sensitivity was lower in young participants compared to older participants (1.9 ± 0.59 mA vs. 2.42 ± 1.03 mA; p = 0.021). Young participants also performed better in smell (Score 11.13 ± 0.86 vs 9.3 ± 1.93; p < 0.001) and taste examinations (Score 11.83 ± 1.86 vs 8.53 ± 3.18; p < 0.001). ANCOVA revealed a statistical association between sensitivity and smell ( p = 0.08) that was moderated by age ( p = 0.044). Electrical threshold testing at the anterior faucial pillar is a simple, safe, and accurate diagnostic measure of oral sensitivity. We detected a decline of oral sensitivity, taste, and smell in older adults. Trial registration: Clinicaltrials.gov, NCT03240965. Registered 7th August 2017— https://clinicaltrials.gov/ct2/show/NCT03240965 .
... Because the activation of gag reflex contracts the pharyngeal wall and moves hypopharynx upward and may visualize the glottis (6,(14)(15)(16), and thus the airway could be easily evaluated, we hypothesized that our new test "Laryngoscopic Exam Test (LET)" could be a reliable predictor for difficult laryngoscopy and tracheal intubation. Thus, we designed this observational study in patients undergoing general anesthesia. ...
Article
Airway assessment is fundamental skill for anesthesiologists and failure to maintain a patient's airway is the tremendous cause of anesthesia-related morbidity and mortality. None of the tests which have recommended for predicting difficult intubation stands out to be the best clinical test or have high diagnostic accuracy. Our study aimed to determine the utility of a new test as "laryngoscopic exam test (LET)" in predicting difficult intubation. Three hundred and eleven patients aged 16-60 years participated and completed the study. Airway assessment was carried out with modified Mallampati test, upper lip bit test and LET preoperatively, and Cormack and Lehane's grading of laryngoscopy were assessed during intubation as a gold standard, and difficult laryngoscopy was considered as Cormack and Lehane's grade ΙΙΙ or ΙV of laryngoscopic view. The incidence of difficult intubation was 6.1%. The LET showed higher sensitivity, specificity, and accuracy (P<0.05), without revealing significant differences among three tests (P=0.375). The LET is a simple bedside test and an alternative method for predicting difficult intubation.
... [14] Several studies suggest the importance of distraction in decreasing children's dental visit distress. [15,16] The ICG could, therefore, be considered a distraction technique useful for controlling dental fear and anxiety in pediatric patients. [17] The patient's attentiveness was diverted by the ICG chart, which played an important role in alginate impression success. ...
Article
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Objectives The aim of the present prospective study is to determine the effect of an intellectual colored game (ICG) on the severity of gag reflex (GR) and anxiety in children during dental alginate impression. Materials and Methods Forty-one children, aging between 5 and 11 years, having a GR varying from normal to moderate had upper alginate impressions. The children's anxiety was evaluated with a facial image scale (FIS) before (T0) and after first failed impression (T1), then, after playing an intellectual colored game (ICG) at T2, while taking an upper alginate impression. Results 42.9 % of the children had a gag reflex of stage 2 and 31.0 % a facial scale of 3. Initial GR was not significantly associated with the final success of the impression (P =0.260) whereas final impression success was strongly associated with FIS (P <0.001). There was a statistically significant reduction in median GR score from T0 to T2 (P < 0.001) and FIS dropped significantly at T2 with ICG (P < 0.001). Conclusion This study highlights the clinical performance of the intellectual distraction approach in GR management
... However, the limits of agreement for the inter-rater GRT were greater than the differences between the patients with and without dysphagia. These findings are consistent with those of previous studies reporting a lower reliability of this reflex than those of other reflexes in dysphagic patients [37,38]. Although the GRT exhibited less utility for the dysphagic patients, our study does not allow us to rule out its utility for diseases involving lower GRTs, such as motor neuron diseases [39,40] and other laryngo-pharyngeal hypersensitivity states. ...
Article
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FULL TEXT AT: http://rdcu.be/qm0H . There are not reliable methods for measuring laryngo-pharyngeal mechano-sensitivity (LPMS). We aimed to determine the reliability of a new method for measuring LPMS using a new laryngo-pharyngeal esthesiometer (LPEER) in a prospective cohort of dysphagic stroke and non-dysphagic patients. The patients underwent clinical and endoscopic evaluations of swallowing (FESSST). The LPMS assessments consisted of measurements by an expert and a novel rater of the laryngeal-adductor reflex threshold (LART), cough reflex threshold (CRT) and gag reflex threshold (GRT) using the LPEER. We assessed the Bland–Altman limits of agreement, the intraclass correlation coefficients (ICCs) and Spearman correlation coefficients (SCCs). For the inter-rater comparisons, we contrasted the expert and novel raters. A total of 1608 measurements were obtained from 34 dysphagic stroke patients and 33 non-dysphagic patients. The intra-rater ICCs for all reflex thresholds were >0.90. The inter-rater ICCs were 0.87 for the LART, 0.79 for the CRT and 0.70 for the GRT. The intra-rater SCCs for all reflex thresholds were above 0.88 (P < 0.0001). The inter-rater SCC were 0.80 for the LART, 0.79 for the CRT and 0.70 for the GRT (all P < 0.0001). The Bland–Altman plots revealed good agreement for the LART and CRT and moderate agreement for the GRT. The median normal value was 0.14 mN for the LART, 4.4 mN for the CRT and 11.9 mN for the GRT. The median thresholds values in patients with aspiration were LART: 1.31 mN; CRT: 32.9 mN and GRT: 32.9 mN (all P < 0.006 vs normal thresholds). The LPEER exhibited substantial to excellent intra- and inter-rater reliability. FULL TEXT AT: http://rdcu.be/qm0H
... Even the basic dental procedures like impression making especially of the upper arch leads to increased levels of stress suffered by patients, particularly pediatric patients, and often lead to salivation, lacrimation, or even vomiting. According to Davies et al [8], gag reflex does not exist in 37% of the healthy population, whereas some people suffer from severe gag reflex, thereby making dental treatment procedures intolerable for them [3,9e13]. ...
Article
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Objective: To investigate the effect of low level laser therapy (LLLT) on PC6 acupuncture point in suppressing gag reflex, regulating pulse rates and oxygen saturation, thereby reducing the anxiety levels. Materials and Method: A total of 40 patients who demonstrated hyperactive gag reflex in the age group of 4-14 years were included in the study. In Group A (20 patients), maxillary impression was recorded. In the second step, PC6 acupuncture point was stimulated with LLLT followed by recording of second maxillary impression. In group B (20 patients), steps were reversed. Gag reflex, anxiety levels, pulse rate and oxygen saturation levels were assessed. Results: Values of pulse rate and oxygen saturation were regulated to normal, signifying lowered anxiety levels. Gag reflex was also significantly decreased after stimulating PC6 acupuncture point with LLLT. Conclusion: LLLT on PC6 point was found to be effective in lowering anxiety levels as observed by faces modified anxiety rating scale. Further, it was authenticated as the pulse rates were significantly reduced and oxygen saturation levels were significantly increased. Also, gag reflex was significantly controlled when LASER stimulation was done at PC6.
... It is a polysynaptic reflex, which arises at the cortical level and is composed of a palatal and a pharyngeal response. Palatal response comprises an upward movement of the soft palate with an ipsilateral deviation of the uvula, whereas the pharyngeal response means the contraction of the pharyngeal wall [1,2]. Concomitant During the standard pre-procedural examination, the patients, screened according to eligibility criteria (s. ...
Article
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Background: Gagging during transesophageal echocardiography examination (TEE) can be distressing and even dangerous for patients. The needling of acupuncture point CV24 was described to be effective in reducing the gag reflex during TEE in patients with ischemic stroke or transient ischemic attack. Methods: We describe a proposal for a prospective, randomized, patient, practitioner and assessor-blinded, single-center trial with two arms/groups; real acupuncture will be compared to placebo acupuncture. A total of 60 (30 per group) patients scheduled for elective TEE in order to exclude a cardiac embolic source, endocarditis or for valve failure evaluation will be recruited according to patients’ selection criteria and receive either indwelling fixed intradermal needles at acupoints CV24 and bilateral PC6 or placebo needles at the same areas. Patients, the practitioners who will perform the TEE procedure, and the assessor of the outcome measures will be unaware of the group’s (real or placebo) allocation. Results: The primary outcome is the intensity of gagging, measured using verbal rating scale (VRS-11) from 0 = no gagging to 10 = intolerable gagging. Secondary outcomes include the incidence of gagging, the use of rescue medication, patients’ satisfaction with relief of unwanted side effects during TEE procedure, success of patients’ blinding (patients’ opinion to group allocation), heart rate and oxygen saturation measured by pulse oxymetry. Conclusions: To study the effects of acupuncture against gagging during TEE, we test the needling of acupoints CV24 and PC6 bilaterally. A placebo acupuncture is used for the control group. Trial registration number: NCT NCT0382142.
... Sometimes, however, one's gag reflex can be oversensitive and impede important activities, such as going to the dentist [2]. Nearly 74% of people possess a gag reflex, and it ranges in intensity from minor to strong enough to interfere with daily activities of life [4]. Major factors contributing to intense gag reflexes can be divided into two categories: somatogenic and psychogenic [3,5]. ...
Article
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Objectives: The aim of this study was to devise a reliable and valid survey to predict the intensity of someone’s gag reflex. Material and Methods: A 10-question Predictive Gagging Survey was created, refined, and tested on 59 undergraduate participants. The questions focused on risk factors and experiences that would indicate the presence and strength of someone’s gag reflex. Reliability was assessed by administering the survey to a group of 17 participants twice, with 3 weeks separating the two administrations. Finally, the survey was given to 25 dental patients. In these cases, patients completed an informed consent form, filled out the survey, and then had a maxillary impression taken while their gagging response was quantified from 1 to 5 on the Fiske and Dickinson Gagging Intensity Index. Results: There was a moderate positive correlation between the Predictive Gagging Survey and Fiske and Dickinson’s Gagging Severity Index, r = +0.64, demonstrating the survey’s validity. Furthermore, the test-retest reliability was r = +0.96, demonstrating the survey’s reliability. Conclusions: The Predictive Gagging Survey is a 10-question survey about gag-related experiences and behaviours. We established that it is a reliable and valid method to assess the strength of someone’s gag reflex.
... Although the cough reflex differs from individual to individual [21], its incidence is a surrogate measure of the quality of awake fibreoptic intubation [4]. In studies using spray-as-you-go techniques, coughing occurred in between 55% and 81% of patients [4,13,14,17,22]. ...
Article
We compared the Enk Fiberoptic Atomizer Set(™) with boluses of topical anaesthesia administered via the working channel during awake fibreoptic tracheal intubation in 96 patients undergoing elective surgery. Patients who received topical anaesthesia via the atomiser, compared with boluses via the fibreoptic scope, reported a better median (IQR [range]) level of comfort: 1 (1-3 [1-10]) vs. 4 (2-6 [1-10]), p < 0.0001; experienced a reduced total number of coughs: 6 (3-10 [0-34]) vs. 11 (6-13 [0-25]), p = 0.0055; and fewer distinct coughing episodes: 7% vs. 27% respectively, p = 0.0133. The atomiser technique was quicker: 5 (3-6 [2-12]) min vs. 6 (5-7 [2-15]) min, p = 0.0009; and required less topical lidocaine: 100 mg (100-100 [80-160]) vs. 200 mg (200-200 [200-200]), p < 0.0001. Four weeks after nasal intubation, the incidence of nasal pain was less in the atomiser group compared with the control group (8% vs. 50%, p = 0.0015). We conclude that the atomiser was superior to bolus application for awake fibreoptic tracheal intubation.
... The oesophageal dysmotility is most common in the very old (Hollis and Castell, 1974). The gag reflex is absent in 43% of elderly subjects (Davies et al., 1995).The oesophageal sphincteric and peristaltic function deteriorates with ageing (Grande et al., 1999;Ren et al., 1993;Robbins et al., 2006); changes in peristalsis are seen from as early as 40 years of age (Gregersen et al., 2008). ...
Article
Physiological functions of the two extreme ends of the age spectrum, children (<18 years old) and older adults (aged 65 years and over), differ from healthy young adults. This consequently affects the pharmacokinetic profiles of administered drugs, which, in turn, impacts upon clinical practice and drug therapy. The gastrointestinal milieu acts as a distinct and vital organ regulating the dissolution, absorption and metabolism of orally ingested drugs. Age-mediated alteration in the physiology and function of the gut can reshape the pharmacokinetics of certain drugs. However, our understanding on this topic is limited. This article references the gut physiology of healthy adults to capture the available evidence in the literature on the extent and nature of the changes in childhood and older age. The gut, as an organ, is examined with regards to the effect of age on luminal fluid, microbiota, transit and motility, and the intestinal mucosa. Whilst drastic developmental changes were observed in certain aspects of the gastrointestinal environment, the examination reveals significant gaps in our knowledge in the physiology and function of the developing or ageing gut. The revelation of the unknown paves the way towards a better characterization of the human gastrointestinal tract for optimized drug therapy in children and older adults.
... In a review article, Bassi classified the causes of gag reflex into iatrogenic factors, systemic disorders, and psychological disorders. [4] In their study, Davies et al., argued that gag reflex does not exist in 37% of the healthy population, [5] while some people suffer from severe gag reflex, making dental treatment procedures intolerable for them. [1,3,4,6,7] Thus, appropriate management of severe gag reflex is of considerable importance. ...
Article
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Introduction: Hyperactive gag reflex can make dental treatment procedures intolerable for some patients; so, it is highly important for the dentist to control it. Acupuncture is a technique used to control this phenomenon. In this study, the effects of two acupoints, anti-gagging and P6, on the gag r eflex control were analyzed. Materials and Methods: In this clinical trial study, a total number of 100 healthy people were classified into four groups. Acupuncture and psuedo-acupuncture procedures were performed on anti-gagging and P6 points based on the group. Before and after acupuncture or pseudo-acupuncture, gag reflex severity was measured via stimulation of the soft palate, tonsils, and root of the tongue. Obtained data was analyzed using statistical package of social sciences (SPSS) 22 statistical software. Results: Acupuncture reduced gag reflex at both points, but psuedo-acupuncture did not reduce the gag reflex. Moreover, no significant difference was observed between acupuncture on P6 and anti-gagging points. Conclusion: Acupuncture on anti-gagging and P6 points can be effective in controlling the gag reflex during routine dental procedures.
... 15 Injuries to the hypoglossal nerve present with dysphagia and loss of taste over the posterior one third of the tongue and palate and an absence of gag reflex because the sensory limb of the reflex is mediated through the glossopharyngeal nerve and the motor component through the vagal nerve. 17 Patients with irritation of the ninth cranial nerve typically present with glossopharyngeal neuralgia, complaining of unilateral pain in the back of the throat and tongue and in the ear. Glossopharyngeal neuralgia is usually caused by vascular compression at the root entry zone of the glossopharyngeal nerve. ...
Article
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Background: Glossopharyngeal schwannomas are rare tumors. Clinical and radiological presentation closely resembles those of vestibular schwannomas. Their clinical presentation varies from vestibulocochlear dysfunction to glossopharyngeal and vagal nerve dysfunction. Case: We report a case of a small glossopharyngeal schwannoma presenting with intractable recurrent sudden episodes of vomiting that subsided after tumor resection. This is the only case in the literature of glossopharyngeal schwannoma presenting with nerve irritation in the form of intractable emesis. Conclusion: Small Glossopharyngeal Schwannomas can present with irritative symptoms of the ninth cranial nerve causing vomiting refractory to medical treatment. Intracranial imaging should be considered in the investigation of unexplained intractable vomiting even if the gross neurological exam is normal.
... • An absent unilateral gag reflex suggests an abnormality, unlike an absent bilateral gag reflex which is seen in healthy individuals. 25 • Hypertension from baroreceptor reflex damage would be a feature of bilateral ninth nerve lesions rather than unilateral. • Compressions such as internal carotid artery dissections or aneurysms must be considered and ruled out as the evidence is easily obtainable. ...
Article
Isolated palsy of the glossopharyngeal nerve is rare. We report the case of an elderly patient with unilateral right glossopharyngeal nerve palsy secondary to extra cranial ischemia. On examination there was no other deficit other than an absent right gag reflex. She was diagnosed clinically with ischemic stroke of the ninth nerve, and her daily dose of aspirin was increased from 81 mg to 325 mg. Magnetic resonance imaging of the brain showed a normal brainstem and cerebellum with patent intracranial circulation. Total resolution of the paralysis was seen 2 months later. The possible mechanisms suspected were diabetic or hypertensive stenosis of the vasa nervorum or compression of the ninth nerve by an internal carotid artery dissection or aneurysm. This article discusses the various etiologies and mechanisms of this rare condition. It is unique because of the nerve's location and relationship to other structures.
... Pain and nasal irritation symptoms are more prevalent during TNFL procedures, while gag reflex stimulation is more common during TORL [4]. The gag reflex is caused by stimulation of the pharyngeal and velar regions, which occur when the base of the tongue, the soft palate, the uvula and the posterior pharyngeal structures are touched [16]. The gag reflex increases heart rate and systemic blood pressure [17]. ...
Article
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Objectives This study compared the impact of transoral rigid laryngoscopy (TORL) and transnasal flexible laryngoscopy (TNFL) methods on intraocular pressure (IOP).Methods This study included 100 patients, with 50 patients undergoing a TORL, and 50 patients a TNFL. Before procedure IOP values were recorded by an ophthalmologist using Icare Pro tonometry, also immediately post procedure, and at the 15th, 30th and 60th minute after laryngoscopy.ResultsBoth groups were similar in terms of age, gender, mean body mass index (BMI), and pre-laryngoscopy IOP values. When the TNFL and TORL groups were compared, no significant differences were observed between pre-laryngoscopy, and 60th minute IOP values (p = 0.891, p = 0.149, respectively). IOP values measured immediately after laryngoscopy, and at the 15th and 30th minute were significantly higher in the TORL group (p < 0.001, p < 0.001, p = 0.002, respectively).Conclusions We demonstrated higher IOP fluctuations in the TORL group, when compared to the TNFL group. For this reason, TNFL may be considered a safer method for evaluating laryngeal tissues in conditions that require lower IOP fluctuation as in glaucoma. However, further studies are required to clarify the exact effects of IOP fluctuations during TNFL and TORL in patients with glaucoma.
... How much stimulation is required to trigger the gag reflex varies from person to person, with some studies showing that the gag reflex reportedly does not exist in 37% of healthy people. 13 When food items have been improperly chewed, the gag reflex may be triggered to bring the food back into the oral cavity proper for further chewing. 14 Feedback from oral receptors is necessary to guide chewing strength, movement and duration. ...
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Background: Many medications are available as solid oral dosage forms such as tablets and capsules; however, some people find these medications difficult to swallow. Aim: To identify whether certain psychological, oral sensory, and oral motor characteristics contribute to medication swallowing difficulties. Methods: A sample of healthy adults from two academic institutions in Brisbane were assessed for their experiences with swallowing solid oral dosage forms, food preferences, and food neophobia. The gag reflex, oral cavity size, fungiform papillae count, and chewing efficacy were also evaluated followed by a capsule-swallowing task. Primary outcome was the incidence of medication swallowing difficulties. Secondary outcomes were the association of medication swallowing difficulties with psychological, oral sensory, and oral motor factors. Results: Of 152 subjects, 32% reported difficulty swallowing tablets or capsules whole. This group was significantly more likely to have had a memory of choking on medications compared to those without medication swallowing difficulties (OR = 7.25, p < 0.05). Current medication swallowing difficulties were significantly associated with a smaller mouth cavity size (OR = 2.98, p < 0.05), a higher density of taste receptors on the tongue (OR = 3.27, p < 0.05), and were higher among those who chewed a jelly candy to non-homogenous particle size (OR = 4.1, p < 0.05). Current medication swallowing difficulties were associated with lower confidence in swallowing large capsules (000 size: OR = 0.47, 00 size: OR = 0.39, p < 0.05). No associations were found between medication swallowing difficulties and the gag reflex or food neophobia. Conclusion: A combination of heightened oral perception characterized by a small oral cavity and high taste sensitivity compounded by a past choking episode on medications may be precipitating factors for medication swallowing difficulties. These factors may be helpful in identifying individuals who are more likely to experience difficulty swallowing medications.
... Presence of gag and cough reflexes has been used to inform the need for intubation in patients with altered mental status but is not an adequate predictor of aspiration risk. The presence of the gag reflex varies, even among patients with normal mental status, and testing gag or cough reflexes may actually increase the risk of vomiting and aspiration [29][30][31][32][33][34][35]. Therefore, in our opinion, the practice of attempting to elicit a gag reflex in a poisoned patient should be abandoned. ...
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Introduction: Endotracheal intubation (ETI) is an essential component of the supportive care provided to the critically ill patient with pharmaceutical poisoning; however, specific nuances surrounding intubation including techniques and complications in the context of pharmaceutical poisoning have not been well elucidated. Discussion: A search of the available literature on ETI in pharmaceutical-poisoned patients was undertaken using Medline, ERIC, Cochrane database, and PsycINFO using the following MeSH and keyword terms: ("toxicology" OR "poisons" OR "drug overdose" OR "poisoning") AND ("intubation, intratracheal" OR "intubation, endotracheal" OR "airway management" OR "respiration, artificial"). A hand-search was also performed when the literature in the above search required additional conceptual clarification, including using the "Similar Articles" feature of PubMed, along with reviewing articles' reference lists that discussed intubation in the context of a poisoning scenario. Articles with any discussion around the ETI process in the context of a pharmaceutical poisoning were then included. Intubation may be performed in patients poisoned with pharmaceuticals in the context of both single and multiple organ dysfunction including central and peripheral nervous system, pulmonary, or cardiovascular toxicity with hemodynamic instability, or localized effects resulting in mechanical airway obstruction. Certain classes of poisonings may require modifications to the standard rapid sequence induction airway management algorithm. Conclusions: ETI is a key component of the supportive care provided to the patient poisoned by a pharmaceutical agent. Clinicians should be aware of the spectrum of toxicities that can necessitate intubation, as well as airway management nuances that are specific to various poisoning presentations.
... Analysis of the administrated pharmaceuticals could not fully explain the exceptions of the two participants (4 and 9) who showed an identical stiffness under GA and AR. 2. Upper airway reflexes, activated by intubation under GA, are not always completely suppressed during general anesthesia (Tagaito et al., 1998). Such (remnants of) reflexes are unequally pronounced among humans and depend on the depth of anesthesia, which could explain the observed patient-specific singular absence of stiffening in participant 4 and 9 (Davies et al., 1995) but could not be confirmed. 3. The lack of movements and administered drugs under GA alter blood flow and perfusion. ...
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Tongue cancer treatment often results in impaired speech, swallowing, or mastication. Simulating the effect of treatments can help the patient and the treating physician to understand the effects and impact of the intervention. To simulate deformations of the tongue, identifying accurate mechanical properties of tissue is essential. However, not many succeeded in characterizing in-vivo tongue stiffness. Those who did, measured the tongue At Rest (AR), in which muscle tone subsides even if muscles are not willingly activated. We expected to find an absolute rest state in participants ‘under General Anesthesia’ (GA). We elaborated on previous work by measuring the mechanical behavior of the in-vivo tongue under aspiration using an improved volume-based method. Using this technique, 5 to 7 measurements were performed on 10 participants both AR and under GA. The obtained Pressure-Shape curves were first analyzed using the initial slope and its variations. Hereafter, an inverse Finite Element Analysis (FEA) was applied to identify the mechanical parameters using the Yeoh, Gent, and Ogden hyperelastic models. The measurements AR provided a mean Young’s Modulus of 1638 Pa (min 1035 – max 2019) using the Yeoh constitutive model, which is in line with previous ex-vivo measurements. However, while hoping to find a rest state under GA, the tongue unexpectedly appeared to be approximately 2 to 2.5 times stiffer under GA than AR. Explanations for this were sought by examining drugs administered during GA, blood flow, perfusion, and upper airway reflexes, but neither of these explanations could be confirmed.
... 2,3 Assessment of the gag reflex is routine but does not correlate well with laryngeal closure and airway protection 4,5 ; the gag reflex may be absent in up to 37% of healthy subjects. 6 In the acute setting, a GCS score less than or equal to 8 has been described as both sensitive and specific for predicting the need for endotracheal intubation, 7 applied not only in trauma but also in patients with stroke, intoxication, and other etiologies of altered mental status. 1 Several studies have demonstrated that patients with GCS less than or equal to 8 commonly have airway obstruction, hypoxemia, and hypoventilation, 8 resulting from pooled secretions, anatomic compression, or foreign-body aspiration. While the GCS is routinely employed in the emergency department and by emergency medical services (EMS) as part of a triage process to assess patients for intubation, the GCS was not developed for this purpose and does not address any of the primary issues related to airway protection-cough, the ability to manage secretions in the upper airway, or the acuity or anticipated course of the primary neurologic process. ...
Chapter
Dieses Kapitel beschäftigt sich mit der Dokumentation und der klinischen bzw. apparativen Diagnostik von Dysphagien. Zunächst wird auf Klassifikationssysteme des deutschen Gesundheitssystems eingegangen, in denen Dysphagien und assoziierte Störungen (wie Sondenernährung und Trachealkanülen) erfasst bzw. dokumentiert werden können: ICF, ICD-10-GM-2017, OPS- und DRG-Katalog; dabei wird auch der Stellenwert von Dysphagien im Rahmen des Bundesteilnahmegesetzes und der reformierten Pflegeversicherung berücksichtigt. Es folgt ein Abschnitt, in dem sehr ausführlich eingegangen wird auf verschiedene Screeningverfahren (insbesondere bezüglich Dysphagien und Aspirationen in der akuten Schlaganfallphase) und auf die ausführliche klinische Schluckuntersuchung. Danach werden die drei wichtigsten apparativen Verfahren der Dysphagiologie ausführlich dargestellt: die Videoendoskopie und die Videofluoroskopie des Schluckens sowie die Manometrie von Pharynx und Ösophagus; es werden jeweils Indikationen, Methodik, Nebenwirkungen, Stellenwert in Diagnostik und Therapie sowie Vor- bzw. Nachteile der einzelnen Verfahren erörtert. Der letzte Abschnitt befasst sich mit der Bedeutung klinischer und apparativer Diagnostikinstrumente für die Verlaufskontrolle; dabei geht es unter anderem um Fragen, wann welche Verlaufsdiagnostik indiziert ist, nach welchen Kriterien sie bewertet wird und welche Konsequenzen sich aus den Befunden ergeben
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La Intubación traqueal de emergencia en el ámbito hospitalario se realiza usualmente en los servicios de urgencias o en áreas de atención de pacientes críticos. La necesidad de intubación puede ser evidente, como en parada cardiorrespiratoria o en coma profundo, pero a veces la decisión de intubar puede ser el resultado de una evaluación dinámica sobre la base de un deterioro progresivo a pesar del manejo médico y la asistencia respiratoria no invasiva.
Chapter
Head injury is an important cause of death and disability particularly in adolescents and young adults. This remains so despite significant advances in the understanding of the pathophysiology of brain injury, in the diagnosis and evaluation of intracranial injuries, and in the monitoring of head injured patients in the intensive care unit (ICU). Treatment modalities have been traditionally based on reducing and preventing raised intracranial pressure (ICP). However, the focus of treatment has changed to optimizing cerebral substrate utilization.
Chapter
Texture-modified meals are provided to people with chewing and swallowing difficulties, such as those with dysphagia. Foods may be pureed, chopped, mashed, minced or made soft to reduce the likelihood of choking. The texture modification process can deplete the nutrient density of these diets, inadvertently increasing potential for malnutrition. At its core, patients with dysphagia require food that is moist and cohesive to promote safe and efficient swallowing. This chapter details the eating hazards and risks of dysphagia patients along with their needs from a texture-modified diet. It outlines the specific criteria of texture-modified food, addressing issues relating to ‘institutional food’. The chapter concludes with descriptions of texture-modified food classifications and the variations in this terminology seen on an international scale.
Chapter
Altered mental status is commonly encountered in the Neurological Intensive Care Unit, and the differential diagnosis is broad. The general and neurological examinations can give many clues both to the neurological and non-neurological causes. Neuroimaging, neurophysiological tests, and laboratory studies are often helpful in identifying the etiology, which can run the entire gamut of disease processes including vascular, neoplastic, metabolic, or infectious. In cases of brain death, it is essential to understand the diagnostic criteria as well as adjunctive studies.
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Airway obstruction and respiratory failure are common complications of neurological emergencies. Anesthesia is often employed for airway management, surgical and endovascular interventions or in the intensive care units in patients with altered mental status or those requiring burst suppression. This article provides a summary of the unique airway management and anesthesia considerations and controversies for neurologic emergencies in general, as well as for specific commonly encountered conditions: elevated intracranial pressure, neuromuscular respiratory failure, acute ischemic stroke, and acute cervical spinal cord injury.
Thesis
Older people with swallowing disorders are faced with the risk of malnutrition and this affects the quality of life adversely. The aim of this study; determination of nutritional status in elderly with dysphagia, examining the relationship between food consumption and masticatory performance, as well as the determination of nutrient deficiency and to examine the effect of dysphagia on quality of life in and investigate malnutrition or risk of malnutrition in elderly with swallowing disorders. The study was carried out on 55 (27 men, 28 women) patients with dysphagia at Swallowing Disorders Research and Practice Center and 62 (24 men, 38 women) healthy elderly people as control group at the Geriatrics Clinic in Hacettepe University in April 2015- April 2016. General characteristics, malnutrition status, oral health status, physical activity level and a questionnaire assessing their quality of life were applied all elderly. Also, food consumption records (1 day) and some anthropometric measurements were taken of all the elderly. Masticatory performances of the elderly were evaluated by a special gum. At the end of the study, it is determined that 69.1% of patients had bad, 27.3% of patients had normal and 3.6% of patients had a better masticatory performance. In control group, this case is accordingly 53.2%, 30.6% and 16.1% (p<0.05). According to Mini Nutritional Assessment (MNA), 49.1% of patients were malnourished and 45.4% of patients are at risk of malnutrition. In the control group, it is discovered that 9.7% of the elderly were malnourished and 41.9% of the elderly were at the risk of malnutrition (p<0.001). Body weight, body mass index (BMI), waist circumference, mid-upper arm circumference and handgrip strength in men with swallowing disorders were different from the control group (p<0.05). When women with swallowing disorder compared with women in the control group; mid-upper arm circumference, femur bicondylar size and handgrip strength were different (p<0.05). Male elderly in the case group, energy, protein, fiber, vitamin A, vitamin B1, vitamin B2, niacin, vitamin B6, folic acid, calcium, magnesium and zinc; in female elderly; energy, protein, fiber, vitamin B1, niacin, vitamin B6, folic acid, calcium, magnesium, iron and zinc intakes were considered as inadequate. Regarding the relationship between Geriatric Oral Health Assessment İndex (GOHAI) and Eating Assessment Tool (EAT-10), EAT-10 and BMI, EAT-10 and Understanding of Quality of Life (SWAL-QOL) it is found that there was a strong correlation (p<0.05). MNA and GOHAI, MNA and EAT-10, MNA and BMI, MNA and BI, MNA and masticatory performance, MNA and SWAL-QOL, GOHAI and Barthel Index (BI), GOHAI and SWAL-QOL, GOHAI and masticatory performance was observed a moderate correlation (p<0.05). In conclusion, regarding MNA, it is discovered that elderly with swallowing disorders had a high risk of malnutrition and there was a strong relationship between the quality of life and swallowing disorders. Therefore, it is crucial to know the potential changes in nutritional status after diagnosed with swallowing disorders. Moreover, older people should be followed by a dietitian and a healthy and balanced diet in accordance with their specific requirements consumption should be provided for the elderly at every stage.
Article
Background: No studies assessing the association between gagging and dental fear are available in pediatric samples. Aim: To assess the psychometric properties of the Greek version of the Gagging Assessment Scale (GAS), to explore the prevalence of gagging, and to evaluate the relationship between gagging and dental fear in a pediatric sample. Design: A total of 849 8- and 14-year-old children filled out a questionnaire consisting of demographic items, the Greek version of the GAS, and the Greek Children's Fear Survey Schedule Dental Subscale (CFSS-DS); the older children also completed the Greek version of the Modified Dental Anxiety Scale (MDAS). The short form of dentist part of the Gagging Problem Assessment (GPA-de-c/SF) was used to objectively assess gagging. Results: A total of 51 children (6.0%) demonstrated gagging on the GPA-de-c/SF. Children rated as gaggers on the GPA-de-c/SF had significantly higher GAS scores. There were no relationships between GPA-de-c/SF and the CFSS-DS or MDAS. The GAS ratings were significantly correlated with the CFSS-DS (rho = 0.420, P < 0.001) and MDAS (rho = 0.429, P < 0.001). The internal consistency was good (Cronbach's alpha = 0.697). Conclusions: The GAS demonstrated good psychometric properties. Dental fear was correlated with the self-report gagging assessment, but not with the objective gagging assessment.
Article
Objective To describe and compare the findings of endoscopic sensory assessment in COPD patients and healthy controls. Design A prospective cross‐sectional study. Setting Otorhinolaryngology outpatient clinic at a university hospital. Participants 27 adults with COPD and 11 age‐matched healthy controls. Main outcome measures Group differences in light‐touch endoscopic tests of pharyngeal and laryngeal sensation, controlling for pooled salivary secretions in the pharynx and laryngo‐pharyngeal reflux as measured by the Reflux Finding Score (RFS). Results A significant difference in laryngeal sensation was found between the study groups (p = 0.047), with reduced laryngeal sensation in the COPD patients. Additionally, a significant relationship was found between impaired oropharyngeal sensation and the presence of pooled salivary secretions in the pharynx (p = 0.018), especially in the pyriform sinuses (p = 0.012). No differences in the frequency of abnormal Reflux Finding Scores were found between groups. Conclusion Individuals with COPD were significantly more likely to present with impaired laryngeal sensation. Additionally, impaired sensation in the oropharynx was associated with pooled salivary secretions in the pharynx.
Article
Background: Excessive gag reflex could be problematic for adequate dental care. Although various factors may increase the susceptibility to gagging, its contributing factors have not been fully determined. Objective: This study aimed to determine whether gag reflex was associated with tactile sensitivity and psychological characteristics. Methods: 15 volunteers of healthy males and females each were recruited for this study. After completing a questionnaire describing the self-perceived gag reflex activity, a disposable saliva ejector was inserted along the palate into the mouth until gagging was evoked. The ratio of the insertion depth to the palatal length was used as an index for the gagging threshold. The two-point discrimination (TPD) and Semmes-Weinstein monofilament (SWM) tests were performed to assess the tactile sensitivity of the palatal regions (hard palate, anterior and posterior soft palate). The Symptom Checklist-90-Revised was used to investigate the relationship between the gagging threshold and the psychological status. Results: Our findings showed that the gagging threshold had a significant positive correlation with the TPD and SWM thresholds on the hard palate. The psychological profiles of psychoticism and hostility score were also significantly correlated with the gagging threshold. However, there were no significant differences in the tactile and gagging thresholds, as well as the psychological profiles, between males and females. Conclusion: Our results suggested that the tactile sensitivity of the anterior palate is a determining factor for the gagging threshold and implied that the initial response of the oral entry site to stimulation may lead to the development of gag reflex.
Article
Product texture and mouthfeel contribute significantly to product appreciation. For medical nutrition products (MNP) the textural properties also contribute to both swallowing efficiency and safety, therefore impacting the nutrition and fluid intake of individuals in need of adapted textures (e.g. dysphagia, poor dental status). The need for an international terminology in a medical context has been expressed through several initiatives. The main reason was the inconsistency in mouthfeel terminology usage per country and care provider. A consistent terminology is important when selecting and preparing a safe and acceptable MNP. Current terminology is not specific to MNP, making it challenging to develop optimal MNP and communicating about them. The objective of the current study was to develop a hierarchically structured mouthfeel terminology suited to MNP. This terminology was developed with expert sensory panelists describing the mouthfeel terminology of 32 products, resulting in 9 umbrella terms and 51 individual attributes. To categorize the terminology appropriately and to make it accessible to a wide range of users, Taxonomic Free Sorting (TFS) was used to develop a hierarchical structure which is represented as a wheel. This structured terminology should assist sensory expert panels, Health Care Professionals (HCP), carers, individuals in need of adapted textures, chefs, food technologists and sensory scientists in their interpretation and use of terminology related to mouthfeel of MNP. Ultimately the mouthfeel wheel was developed as a communication tool to support product improvement and selection of MNP by HCP, with an optimized mouthfeel for individuals in need of adapted textures.
Article
Background: The decision to extubate brain-injured patients with residual impaired consciousness holds a high degree of uncertainty of success. The authors developed a pragmatic clinical score predictive of extubation failure in brain-injured patients. Methods: One hundred and forty brain-injured patients were prospectively included after the first spontaneous breathing trial success. Assessment of multiparametric hemodynamic, respiratory, and neurologic functions was performed just before extubation. Extubation failure was defined as the need for ventilatory support during intensive care unit stay. Extubation failure within 48 h was also analyzed. Neurologic outcomes were recorded at 6 months. Results: Extubation failure occurred in 43 (31%) patients with 31 (24%) within 48 h. Predictors of extubation failure consisted of upper-airway functions (cough, gag reflex, and deglutition) and neurologic status (Coma Recovery Scale-Revised visual subscale). From the odds ratios, a four-item predictive score was developed (area under the curve, 0.85; 95% CI, 0.77 to 0.92) and internally validated by bootstrap. Cutoff was determined with sensitivity of 92%, specificity of 50%, positive predictive value of 82%, and negative predictive value of 70% for extubation failure. Failure before and beyond 48 h shared similar risk factors. Low consciousness level patients were extubated with 85% probability of success providing the presence of at least two operating airway functions. Conclusions: A simplified clinical pragmatic score assessing cough, deglutition, gag reflex, and neurologic status was developed in a preliminary prospective cohort of brain-injured patients and was internally validated (bootstrapping). Extubation appears possible, providing functioning upper airways and irrespective of neurologic status. Clinical practice generalizability urgently needs external validation.
Thesis
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Due to the complex anatomy of the tongue, it is not possible to predict functional consequences after surgical treatment of tongue cancer based on reasoning and experience alone. The ambition of the 'Virtual Therapy' project is to develop a Digital Twin model based on actual physics and anatomy of the head and neck region. This model could theoretically assist in predicting functional loss, thereby assisting the physician and patient to better understand the effects of treatment on function. In this thesis various aspects in creating a biomechanical finite element (FE) models of the tongue have been researched. A method was created to enable virtual surgery on a biomechanical models of the tongue by means of a few mouse clicks. The FE analysis causes the tissue to realistically deform when simulating sutures and fibrosis. To personalize the models, an MRI technique called Constrained Spherical Deconvolution (CSD) was used to make intersecting muscle fibers visible in the tongue. In this way, we were able to construct fully personalized models from 10 healthy subjects which correctly predicted the measured tongue movements in 80% of the healthy subjects. Simulating surgery on personalized preoperative tongue models of patients was, unfortunately, less successful due to the artefacts present in the MRI images. In addition to working on biomechanical models, a previously introduced optical tracking method has been developed further to track the tongue in 3D. This method was able to distinguish tongue movements of healthy subjects and patients after treatment with chemoradiation or surgery. Also, an attempt was made to measure the elasticity of the tongue, without muscle tone, in 10 patients under general anesthesia. Unexpectedly, the tongue tissue appeared to be two times stiffer than while awake.
Chapter
Respiratory failure is a common presentation to the emergency department (ED). In addition to supplemental oxygen, noninvasive positive-pressure ventilation (NIPPV) and mechanical ventilation (MV) are tools commonly used for the management of acute respiratory failure. It is important to know the principles of oxygenation and ventilation and how NIPPV and MV can improve gas exchange. There are many modes that can be confusing to practitioners who do not use ventilators frequently. Knowledge of the different ventilator parameters helps so that the most appropriate mode may be selected for the specific clinical scenario. Once on positive-pressure ventilation (PPV), the provider must be able to troubleshoot problems that commonly occur.
Article
Background: No data are available on clinical manifestations and course of norovirus gastroenteritis (NVE) in intestinal allograft (from intestinal and multivisceral transplant recipients, ITR) compared to native intestine (from other allograft recipients, nITR). Methods: This was a retrospective study of solid organ transplant recipients with NVE at two centers from January 1, 2010 to April 1, 2014. Chi-square, t-test, linear and logistic regression analyses were done to compare NVE in ITR vs nITR patients. Results: ITR (45 patients) were compared to nITR (107 patients). ITR were younger (odds ratio [OR]=0.90; P<.0001), less likely to receive anti-lymphocyte induction therapy (OR=0.15; P<.0001), had shorter time from transplant to NVE (OR=0.99; P=.008). On presentation ITR had less frequent nausea (OR=0.11; P<.0001) or vomiting (OR=0.36; P=.01), higher white blood cell count (OR=1.09; P=.001), and higher glomerular filtration rate (OR=1.02; P<.0001). ITR were less likely to receive anti-motility agents (OR=9.6; P<.0001). ITR were more likely to stay longer on intravenous (IV) fluids (OR=1.18; P<.0001); have recurrent NVE (OR=4.25; P <.0001); have longer hospital stay (OR=1.07; P<.0001); develop acute rejection (OR=5.1; P =.006); and have lower overall survival (OR=0.28; P=.006). Conclusions: Compared to nITR, the ITR with NVE were significantly younger, had less nausea and vomiting at presentation, received less anti-motility agents, required more IV fluids, and had longer hospital stay. A trend was seen for lower survival with NVE in ITR. This article is protected by copyright. All rights reserved.
Article
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The incidence of swallowing disorders in early neurological and neurosurgical rehabilitation varies from 51 % to 91 % depending on the underlying disease. Aspiration pneumonia and malnutrition are frequent complications leading to increased mortality and reduced functional outcome. Diagnostic procedures comprise screenings, clinical dysphagia examinations and instrumental techniques as FEES (flexible endoscopic evaluation of swallowing), VFSS (videofluoroscopic swallow study) and high resolution esophageal manometry. Therapeutic approaches include restorative, compensatory and adaptive techniques. It is to be expected that neuromodulative approaches will be a complement to traditional therapy in the future to improve treatment outcome. Important interdisciplinary approaches in dysphagia management are respiratory therapy, individualized nutritional management and pharmacological secretion management.
Article
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Abstract: Statement of problem: Hyperactive gag reflexes in some dental patients may lead to difficulties In the treatment processes. Various methods have been introduced for control of gag reflex in dentistry. Purpose: The aim of this study was to evaluate the effect of inhalation sedation for gag reflex control in patients with hyperactive gag reflexes and improving operation condition during dental treatment. Materials and method: In this clinical trial study 14 healthy adult patients with tow times failure in dental treatment due to the hyperactive gag reflexes were selected for treatment of posterior mandibular teeth. For all patients, treatment was performed under inhalation sedation with 50% N2O and 50% O2. Severity of gag reflexes and operation conditions was evaluated and results were analyzed using Spearman, Mann Whitney and Wilcoxon tests. Results: Of 14 patients under study, 4 patients were men (28.6%) and 10 patients were women (71.4%). Gag reflex during operation was suppressed in 11 patients (77.8%) and "it was active in only three patients (21.4). Dental treatment was performed easily in nine patients (64.2%), while in three patients (21.4%) it was done with difficulty and in two patients (14.3%) no treatment was performed due to hyperactive gag reflex. Complications were not 0bserved during treatment. Conclusion: For reducing gag reflexes and improving the operations condition in patients with severe gag reflexes it is possible to use inhalation sedation (N2O and O2) which is easy to use and safe. In case, this method is not sufficient, treatment should be performed under general anesthesia.
Article
In recent years the prescription opioid overdose epidemic has decreased, but has been more than offset by increases in overdose caused by fentanyl and fentanyl analogues. Opioid overdose patients should receive naloxone if they have significant respiratory depression and/or loss of protective airway reflexes. Patients who receive naloxone should be observed for recurrent opioid effects. Patients with opioid overdose may be admitted to the intensive care unit for naloxone infusions, treatment of noncardiogenic pulmonary edema, autonomic instability, or sequelae of hypoxia-ischemia or cardiac arrest. Primary and secondary prevention are important to reduce the number of people with life-threatening opioid overdose.
Article
Purpose To determine whether transoral rigid laryngeal endoscopy (TORLE) or transnasal flexible fiberoptic laryngoscopy (TNFFL) is more favorable for laryngeal endoscopic examination in the elderly population. Methods This randomized prospective study carried out in a tertiary reference center. TORLE or TNFFL were performed to patients who were over 65 years at their first visit according to randomization list. At their second visit, other method was performed. Patients' physiological parameters (Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and oxygen (O2) saturation before and immediately after laryngeal examination were recorded. Patients' pain-irritation, gag reflex, and dyspnea status were evaluated using visual analog scale after first and second endoscopic examinations. Further patient preferences for TORLE and TNFFL were recorded. Results Of 96 patients included in the study, 69.8% (n = 67) preferred TORLE while 30.2% (n = 29) preferred TNFFL. Major factor influencing patient preferences was pain-irritation in TNFFL. Pain-irritation scores were significantly higher in TNFFL than those in TORLE (p < 0.001). However, no significant difference was found between two methods with respect to gag reflex and dyspnea scores (p = 0.194, p = 0.327, respectively). In TORLE, there was no statistically significant difference between the values measured before and after examination in terms of SBP, DBP, HR, and O2 saturation (p = 0.641, p = 0.134, p = 0.119, p = 0.414, respectively). However, in TNFFL, statistically significant decrease was observed after examination in HR and O2 saturation (p < 0.001, p < 0.001, respectively). Conclusion TORLE is more suitable for laryngeal examination in elderly patients since it is more comfortable for patient and does not change physiological parameters.
Chapter
Esophageal motility disorders can be categorized based on anatomical localization, neurologic control and muscle type involved. The oropharynx and proximal esophagus are composed of striated muscle and are under central nervous system control. In contrast, the distal esophagus is predominantly composed of smooth muscle and is controlled by the enteric nervous system and vagus nerve via peripheral and central nervous system integration. Recognizing these morphologic and functional differences, this chapter on motility disorders of the esophagus first considers oropharyngeal dysphagia, which includes most physiologic aberrations of the upper esophageal sphincter and proximal esophagus, and then focuses on purely esophageal motor disorders that include considerations mainly relevant to the distal esophagus.
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A prospective study was undertaken to define the incidence, duration, and consequences of dysphagia in an unselected group of 91 consecutive patients who had suffered acute stroke. The site of the present lesion and of any previous stroke was determined clinically and was confirmed by computed tomography of the brain or necropsy in 40 cases. Of 41 patients who had dysphagia on admission, 37 had had a stroke in one cerebral hemisphere. Only seven patients showed evidence of lesions in both hemispheres. Nineteen of 22 patients who survived a stroke in a hemisphere regained their ability to swallow within 14 days. Dysphagia in patients who had had a stroke in a cerebral hemisphere was associated in this study with a higher incidence of chest infections, dehydration, and death.
Article
Seventy patients with bilateral strokes underwent neurologic and videofluoroscopic barium swallowing examinations; 34 (48.6%) aspirated. Patients with aspiration were more likely to have posterior circulation strokes, abnormal cough, abnormal gag, and dysphonia. However, patients likely to aspirate can be identified best by the presence of an abnormal voluntary cough, an abnormal gag reflex, or both. The prediction of patients at risk for aspiration was not improved by additional clinical information (ie, presence of dysphonia or bilateral neurologic signs).
Article
This paper reports the results of a blinded study comparing videofluoroscopy with bedside clinical evaluations by speech/language pathologists in the diagnosis of aspiration. One hundred and seven inpatients from a general rehabilitation hospital were evaluated over a four-month period. Of the total patient population, 43 (40%) aspirated at least one consistency of food during videofluoroscopy. Bedside evaluation identified only 18 (42%) of these patients. The positive predictive value of bedside assessment was 0.75; negative predictive value was 0.70. Aspirators on videofluoroscopy were more likely to have brainstem or multilobe central nervous system involvement than nonaspirators. However, there was no statistically significant difference in lesion sites between clinically detected and "silent" aspirators. While the significance of aspiration noted on videofluoroscopy is debatable, it is clear that bedside evaluation alone underestimates the frequency of aspiration in patients with neurologic dysfunction.
Article
Among 47 patients with stroke evaluated clinically and videofluoroscopically, one-half aspirated. Patients with combined cerebral-brainstem strokes with bilateral cranial nerve signs were at greatest risk, but aspiration also occurred in the context of unilateral signs. Dysphonia was the common clinical characteristic of aspirating patients. Single chest roentgenograms were of limited value in predicting aspiration. Outcome was favorable following compensatory oral feeding programs.
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We examined 2,029 volunteers 50 to 93 years of age in a cross-sectional study of nine bedside neurologic tests to determine the frequency of "abnormal" responses in uncomplicated aging (senescence). Rates of abnormal responses remained constant until age 70 years, after which they increased significantly. The number of abnormal signs per subject also increased, especially over 70 years of age. These results provide normative data against which these signs may be compared when applied as a clinical screening battery for diffuse cerebral dysfunction.
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To assess the incidence of lung aspiration in acute stroke, and attempt to identify factors which render such patients at risk of aspiration, consecutive patients admitted to hospital within 24 h of their first symptomatic stroke were studied prospectively. Sixty patients who were conscious, and who did not have any preceding neurological or other cause of dysphagia, were assessed clinically and underwent a bedside water-swallowing test and videofluoroscopy within 72 h of stroke. Twenty-five patients (42%) were seen to aspirate at videofluoroscopy; of these 20% did not have overt dysphagia as detected by a simple water-swallowing test. Factors found to be significantly associated with aspiration were reduced pharyngeal sensation, dysphagia and stroke severity. Aspiration is common in the early period following acute stroke; disordered pharyngeal sensation is an important concomitant of this and should be carefully tested in each patient admitted with acute stroke.
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To determine the effects of MRI white matter hyperintensities (WMH) on cognitive functioning, we used neuropsychologic tests and MRI to study 150 elderly volunteers free of neuropsychiatric or general disease. There were 76 (50.3%) individuals without and 74 (49.7%) with WMH. The latter subset was older (61.3 +/- 6.6 years versus 58.5 +/- 5.8 years, p = 0.005), had a higher mean arterial blood pressure (103.7 +/- 11.4 mm Hg versus 99.9 +/- 10.3 mm Hg, p = 0.03), and a larger ventricular-to-intracranial-cavity ratio (6.3 +/- 5.6% versus 4.7 +/- 1.6%, p = 0.02). Individuals with WMH performed worse than their counterparts without such abnormalities on all tests administered. After adjusting for the group differences in age, arterial blood pressure, and ventricular size, we noted statistically significant results on form B of the Trail Making Test (121.8 +/- 37.8 msec versus 100.3 +/- 47.9 msec, p = 0.04), a complex reaction time task (680.8 +/- 104.9 msec versus 607.1 +/- 93.9 msec, p = 0.001), and the assembly procedure of the Purdue Peg-board Test (27.5 +/- 5.8 versus 30.6 +/- 5.9, p = 0.02). Partial correlations did not reveal any relationship between test scores and the semiautomatically assessed total area of WMH. Our data suggest that the presence of WMH exerts a subtle effect on neuropsychologic performance of normal elderly individuals, which becomes particularly evident on tasks measuring the speed of more complex mental processing.
Dysphagia in acute stroke. Duchen LW, eds. Greenfield's neuropathology
  • Langton R Hewer
  • Wade
  • Dt
Gordon C, Langton Hewer R, Wade DT. Dysphagia in acute stroke. Duchen LW, eds. Greenfield's neuropathology. 5th ed. London: Edward Arnold, 1992:1297. University Department of Geriatric Medicine, Royal Free Hospital School of Medicine (A E Davies MRCP, S P Stone MD);
Dysphagia in acute stroke
  • Gordon
Aspiration following stroke: clinical correlates and outcome
  • Horner