|Year : 2015 | Volume
| Issue : 2 | Page : 70-73
Effect of thermal stimulation on temporal measures in patients with oropharyngeal dysphagia post cerebrovascular stroke
Mohamed Farahat Ibrahim
Consultant, Associate Professor of Phoniatrics Communication and Swallowing Disorders Unit (CSDU), ORL Department, King Abdulaziz University Hospital, King Saud University, Riyadh, Saudi Arabia
|Date of Web Publication||2-Jan-2020|
MD Mohamed Farahat Ibrahim
P. O Box 245, Riyadh, 11411 ORL Department, Communication and Swallowing Disorders Unit (CSDU) King Abdulaziz University Hospital Riyadh
Source of Support: None, Conflict of Interest: None
Background/Objective: Thermal stimulation is considered one of the behavioral therapy that is used to improve and facilitate swallowing mechanism in patients with oropharyngeal dysphagia. The aim of this work was to study the effect of thermal stimulation on different temporal measures of oropharyngeal swallowing in patients with oropharyngeal dysphagia post cerebrovascular stroke.
Materials and Methods: In this study, thermal stimulation was applied to 23 patients with affected temporal measures (prolonged pharyngeal delay time and pharyngeal transit time) in patients with oropharyngeal dysphagia post cerebrovascular stroke.
Results: There was significant statistical difference in pharyngeal delay time pre-thermal stimulation from post-thermal stimulation for all the tested consistencies except thin liquid consistency and significant difference of the pharyngeal transit time only with solid consistency.
Conclusion: The results of this study proved the effectiveness of thermal stimulation in improving the affected changes on temporal measures that occurred with certain consistencies in patients with oropharyngeal dysphagia post cerebrovascular stroke.
Keywords: Dysphagia, thermal stimulation, temporal measures, videofluoroscopy
|How to cite this article:|
Ibrahim MF. Effect of thermal stimulation on temporal measures in patients with oropharyngeal dysphagia post cerebrovascular stroke. Saudi J Otorhinolaryngol Head Neck Surg 2015;17:70-3
|How to cite this URL:|
Ibrahim MF. Effect of thermal stimulation on temporal measures in patients with oropharyngeal dysphagia post cerebrovascular stroke. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2015 [cited 2022 Dec 8];17:70-3. Available from: https://www.sjohns.org/text.asp?2015/17/2/70/274661
| Introduction|| |
Volitional swallowing in humans involves the coordination of both brainstem and cerebral swallowing control regions. Peripheral sensory in puts are necessary for safe and efficient swallowing, and their importance to the patterned components of swallowing has been demonstrated . Swallowing relies on sensory inputs from food or secretions in the oropharynx, which trigger afferents in the trigeminal, glossopharyngealand superior laryngeal nerves ,,. These inputs reach the brainstem regions and are important to the patterned response components of swallowing ,. In neurogenic oropharyngeal dysphagia, patients’ neurological control on swallowing is affected either at the level of swallowing receptors, afferent and efferent neurons, and/or at the swallowing center that may lead to delayed triggering of swallowing reflex that put the patients at risk of penetration and/or aspiration prior to swallowing.
The aim of management of oropharyngeal dysphagia is to prevent pulmonary aspiration, to maintain adequate food and fluid intake, and to correct nutritional deficiencies when present . Augmentation of the oral sensory input before swallowing is considered one of the behavioural therapy for oropharyngeal dysphagia. . Increased sensory input is designed to alert the central nervous system prior to swallow, that a bolus requiring swallow will be introduced. Techniques to heighten sensory input involve presentation of a larger, more viscous or more flavorful bolus such as a sour bolus. They also involve utilizing increased pressure of the spoon in the oral cavity as food is presented, using thermal/tactile stimulation. This can be obtained by utilizing a size 00 laryngeal mirror to rub on the anterior faucial arch, where there are both tactile and cold receptors. This will heighten the sensory input prior to a swallow attempt on saliva or small bolus . So, the aim of this study is to evaluate the effect of sensory enhancement technique using thermal stimulation on the temporal measures, namely the pharyngeal delay time (PDT) of swallowing in patients with oropharyngeal dysphagia post cerebrovascular stroke.
| Subjects and Methods|| |
This prospective study was conducted on 30 consented Saudi subjects with oropharyngeal dysphagia post cerebrovascular stroke who were referred to the swallowing disorders clinics, Communication and Swallowing Disorders Unit, ENT Department, King Khalid University Hospital. King Saud University in the period between January 2012 to May 2013. All the patients were subjected to a comprehensive swallowing assessment protocol, and underwent Modified Barium Swallow (MBS) studies in the fluoroscopy room of Radiology Department, King Khalid University Hospital. At the same session of the MBS, findings were continuously monitored, by experienced phoniatrician and 3 Speech Language Pathologists, for the different volumes and consistencies that were presented to the patients. Thermal stimulation, using crushed ice and laryngeal mirror size 00, were applied to the patients with delayed triggering of pharyngeal response. the videos of those patients were reviewed after the procedure to evaluate the effect of thermal stimulation by measuring the pharyngeal delay time before and after applying thermal stimulation.
The collected data were analysed using SPSS (Statistical Package for Social Science program, version 15, Chicago, Illinois). Wilcoxon signed rank test was used to compare the amount of progress from pre-thermal stimulation to post-thermal stimulation for patients who received it.
| Results|| |
Thirty Saudi patients with oropharyngeal dysphagia were included in this study. They were 16 males (53%) with ages ranging from 20 to 76 years with a mean age of 48.5±15.23 years and 14 females (47%) with ages ranging from 18 to 70 years with a mean age of 44.5±20.87 years [Table 1]. All the patients showed PDT less than 1 second (i.e normal pharyngeal delay time) with thin liquids, 8 patients (27%) showed abnormal PDT with thick liquids, 13 patients (43%) showed abnormal PDT with puree consistency, 13 patients (43%) showed abnormal PDT with soft mechanical consistency [Table 2]. It was noticed that more than one patient had prolonged pharyngeal delay time with more than one consistency.
|Table 2: Distribution of patients according to PDT in the tested consistencies:|
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For the thick liquid consistency, thermal stimulation normalised PDT for 7 patients while one patient improved PDT to be 1-1.5 second [Table 3]. For the puree consistency, thermal stimulation normalised PDT for 10 patients while 3 patient improved PDT to be 1-1.5 second[Table 4]. For the solid consistency, thermal stimulation normalised PDT for 8 patients while 3 patient improved PDT to be 1-1.5 second, and 2 patients improved PDT to be 1.5-2 seconds [Table 5].
|Table 3: Degree of changes in PDT of thick liquids consistency from pre-thermal stimulation to post-thermal stimulation (n=8)|
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|Table 4: Degree of changes in PDT of puree consistency from pre-thermal stimulation to post-thermal stimulation (n=13)|
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|Table 5: Degree of changes in PDT of solids consistency from pre-thermal stimulation to post-thermal stimulation (n=13)|
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| Discussion|| |
Thermal stimulation therapy, an established technique to treat delayed pharyngeal swallow, confirms the influence of sensory perception on swallowing. . Thermal sensitization consists of applying cold (thermal) contact to the base of the anterior faucial arches to pre-stimulate the oral cavity prior to the introduction of a bolus and trigger the swallowing reflex more rapidly. In 1996, Kaatzke-McDonald and his colleagues  studied the effect of cold (cold vs tepid) stimulation of the anterior faucial pillars on swallowing of healthy subjects. They found that cold touch stimulation evoked a significant increase in swallowing on set time and repetitive frequency of swallowing. The results suggest that there are thermo-sensitive receptors in the faucial pillars that promote swallowing when stimulated by cold touch. However, at the same time, Ali et al.  reported that normal pharyngeal swallow response is neither facilitated nor inhibited by prior cold tactile stimulation or topical anaesthesia of the tonsillar pillars.
The current study was conducted on 30 Saudi patients with oropharyngeal dysphagia due to different neurological disorders. Thirteen patients (43%) were found to have prolonged pharyngeal delay time (PDT > 1 second). It was noticed that PDT increase with upgrading the consistency from thick liquid to soft mechanical consistency and this goes with Im et al  who found that puree consistency showed significant higher pharyngeal transit time when compared to thin and thick liquid consistencies in normal subjects. This is because thicker consistencies need more motor effort and, hence, time to be swallowed. So, prolonged pharyngeal delay may indicate motor weakness in pharyngeal swallowing. In the current study, thermal stimulation succeeded to normalize PDT for some patients and decreased PDT for others. Previous studies found that pharyngeal stimulation can induce remarkable increases in the excitability of swallowing motor cortex, which is associated with short-term improvements in swallowing behaviour in dysphagic stroke patients .
Not only thermal stimulation can enhance swallowing reflex and swallowing frequency, some other food’s sensory properties like sour perception [14, 15], salty and sweet boluses ,, olfactory perception ,,,, texture perception ,, and combination of approaches  can promote swallowing in different ways. Recent studies showed that sour taste and cold temperature of the bolus significantly decrease the oral transit time . Most of these studies were on healthy subjects. We recommend conducting different studies to evaluate the effect of different food’s sensory properties in patients with neurogenic oropharyngeal dysphagia.
| Conclusion|| |
Thermal stimulation is one of the techniques used to stimulate and promote swallowing reflex prior to swallowing. In the current study, it showed significant difference in improving the pharyngeal delay time in patients with oropharyngeal dysphagia post cerebrovascular stroke.
This work was supervised by the Research Chair of Voice, Swallowing, and Communication Disorders (RCVASD), King Saud University, Riyadh, Saudi Arabia.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]