Zusammenfassung
HNO-Ärzte werden häufig mit chronischen Schluckstörungen konfrontiert, die nicht kausal
behandelt werden können, insbesondere nach Resektion von Kopf-Hals-Tumoren, bei peripheren
und zentralen Nervenlähmungen und als funktionelle Störung. Da der Gesamterfolg einer
HNO-ärztlichen Behandlung auch von der Fähigkeit einer normalen Nahrungsaufnahme abhängt,
sind eingehende Kenntnisse der Diagnostik und Therapie von Schluckstörungen speziell
für Erkrankungen im HNO-Bereich notwendig. Dazu vermittelt diese Übersichtsarbeit
die wichtigsten Kenntnisse zur Schluckphysiologie, zur Diagnostik (Teil 1) - die HNO-Ärzte
und Phoniater oft interdisziplinär und dabei federführend zu organisieren haben -
und zur operativen und konservativen Therapie (Teil 2) einschließlich der Verordnung
von restituierenden, kompensierenden und adaptierenden Verfahren.
The Management of Dysphagia
Patients with chronic dysphagia are often in need of artificial nutrition; though
being well balanced in terms of energy and vitamins, patients are at a high risk for
the loss of resistance and body weight. Dysphagia also causes a severe drawback of
the overall quality of life. This paper gives an overview of the present management
of dysphagia from the point of view of otolaryngologists, head-neck-surgeons, phoniatricians,
and medical speech-language-voice-pathologists. The physiology of swallowing and typical
symptoms of dysphagia are first explained. Then the current most important diagnostic
procedures as orofacial and laryngeal function analysis, video-endoscopy, and quantitative
assessments, are discussed (part 1). This also includes considerations on bolus viscosity
variation, postures, swallowing maneuvers, and sensory enhancement procedures, while
actual options like botulinum toxin, passy-muir speaking valve, electromyographic
biofeedback, and electrostimulation are also mentioned (part 2).
Abstract
Patients with chronic dysphagia are often in need of artificial nutrition; though
being well balanced in terms of energy and vitamins, patients are at a high risk for
the loss of resistance and body weight. Dysphagia also causes a severe drawback of
the overall quality of life. This paper gives an overview of the present management
of dysphagia from the point of view of otolaryngologists, head-neck-surgeons, phoniatricians,
and medical speech-language-voice-pathologists. The physiology of swallowing and typical
symptoms of dysphagia are first explained. Then the current most important diagnostic
procedures as orofacial and laryngeal function analysis, video-endoscopy, and quantitative
assessments, are discussed (part 1). This also includes considerations on bolus viscosity
variation, postures, swallowing maneuvers, and sensory enhancement procedures, while
actual options like botulinum toxin, passy-muir speaking valve, electromyographic
biofeedback, and electrostimulation are also mentioned (part 2).
Summary
Background: In histologic studies, the volumetric status of the intralabyrinthine fluids is judged
by the position of the endolymphatic membranes. Bulging of the membranes, commonly
known as endolymphatic hydrops, is assumed to be caused by excess of endolymph. The
opposite situation, retraction of the membranes is, however, only incidentally described
and relatively little attention has been paid to its significance. Almost one hundred
years ago Wittmaack described retraction of the endolymphatic membranes, which has
since been considered to be preparation artifact - a concept that essentially remains
unchallenged. To test the validity of this long held premise, we examined two sets
of temporal bones from different centers.
Material and Methods: We studied the following collections: 1. The Wittmaack collection in Hamburg, Germany.
The original material of 67 temporal bones (patient ages 0-92 years, average age 35.2
years) on which Wittmaack based his opinions. 2. For comparison and to exclude age
related phenomena, 125 temporal bones from 73 children between the ages newborn to
ten years (average age 13.4 months, median 1.5 months) from the temporal bone collection
of the Department of Otolaryngology Tufts University School of Medicine. All specimens
were studied by light microscopy. Retraction was defined as depression of Reissner's
membrane toward the stria vascularis and the Organ of Corti in more than one cochlear
turn and was graded into mild, moderate and severe. Additionally the saccule, utricle
and semicircular ducts were examined for collapse.
Results: The reevaluation of the 67 temporal bones described by Wittmaack, including those
of 7 children below the age of 10 years, showed retraction of Reissner's membrane
in 81% compared to 33% of the temporal bones from the Tufts collection. In contrast
to the high incidence of retraction in the cochlear duct, fewer saccules (12%) and
utricles (4%) were collapsed in the Tufts collection. In the Wittmaack collection
no significant differences between the underlying diseases were found, however in
the Tufts collection the group of children who suffered from extracochlear infections
and malignancies had a higher frequency of retraction.
Conclusion: Mild retraction might be to some extent physiologic or even artifactual. Severe retraction,
however, is a definitive finding that is a part of a local or regional otopathologic
process. Of material, it is quite possible that Wittmaack's original observations
of what he called “hypotonic collapse” was of viral origin (viruses were not known
during Wittmaack's time), ototoxicity or even of genetic origin.
Schlüsselwörter
Schlucken - Dysphagie - Aspiration - perkutane endoskopische Gastrostomie - fiberoptische
Schluckuntersuchung - transorale endoskopische Schluckuntersuchung - Mendelsohn-Manöver
- Tracheotomie
Key words
Swallowing - dysphagia - aspiration - percutaneous endoscopic gastrostomy - fiberoptic
evaluation of swallowing - transoral evaluation of swallowing - Mendelsohn-maneuver
- tracheostomy
Key words
Swallowing · dysphagia · aspiration · percutaneous endoscopic gastrostomy · fiberoptic
evaluation of swallowing · transoral evaluation of swallowing · Mendelsohn-maneuver
· tracheostomy
Key words
Histopathology - Children - Viral infection - Reissner's membrane collapse - Labyrinthitis
- Ototoxicity - Stria vascularis
