Zusammenfassung
Im ersten Teil der Publikation wurden diagnostische Verfahren beschrieben, die zum
Ziel haben, den individuellen Pathomechanismus einer chronischen Schluckstörung festzustellen.
Daraus leiten sich verschiedene therapeutische Maßnahmen ab, die isoliert oder kombiniert
angewendet werden können. Die Schwächung des oberen Ösophagussphinkters mit Botulinum-Toxin
ist Patienten mit strukturellen Stenosen oder relativer Sphinkterhyperfunktionen vorbehalten.
Bei tracheotomierten Patienten mit Aspiration kann das Passy-Muir-Stomaventil versucht
werden. Die meisten Fälle können mit einer gezielten Übungstherapie gebessert werden.
Dabei beruht die „Restitution” auf dem Einüben neuer Bewegungsmuster und auf Übungen
zur Verbesserung der Muskelkraft. „Kompensation” beruht auf Übungen, die strukturelle
und/oder funktionelle Defizite ausgleichen sollen. Durch „Adaptation” werden nicht
weiter zu bessernde Reststörungen durch diätetische Planung der Konsistenz, Temperatur
und Nährstoffgehalt der Nahrung ausgeglichen. In vielen Fällen ist es notwendig, Restitution,
Kompensation und Adaptation miteinander zu kombinieren.
The Management of Dysphagia
In the first part of the article we described diagnostic methods aiming to resolve
the individual underlying pathomechanism of chronic swallowing disorders (dysphagia).
From these, we deducted different therapeutic measures that can be applied either
alone or in combination. Weakening of the upper esophageal sphincter with botulinum
toxin is reserved for patients with structural stenosis or a relative hyperfunction
of the sphincter. It can be tried to use the ”Passy-Muir Valve” for tracheostomized
patients that aspirate. Most cases benefit from a therapy that consists of specific
exercises. ”Restitution” relies on exercises to practice new movement patterns as
well as improvement of muscle strength. ”Compensation” is based on exercises to counteract
structural and/or functional deficits. Through ”adaptation” residual, therapy resistant
disease can be alleviated through dietary planning of consistency, temperature, and
nutrient content of food. In many cases it is necessary to combine ”restitution”,
”compensation”, and ”adaptation”.
Abstract
In the first part of the article we described diagnostic methods aiming to resolve
the individual underlying pathomechanism of chronic swallowing disorders (dysphagia).
From these, we deducted different therapeutic measures that can be applied either
alone or in combination. Weakening of the upper esophageal sphincter with botulinum
toxin is reserved for patients with structural stenosis or a relative hypofunction
of the sphincter. It can be tried to use the ”Passy-Muir Valve“ for tracheostomized
patients that aspirate. Most cases benefit from a therapy that consists of specific
exercises. „Restitution” relies on exercises to practice new movement patterns as
well as improvement of muscle strength. „Compensation” is based on exercises to counteract
structural and/or functional deficits. Through „adaptation” residual, therapy resistant
disease can be alleviated through dietary planning of consistency, temperature and
nutrient content of food. In many cases it is necessary to combine ”restitution“,
”compensation“ and ”adaptation“.
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 · Mendelsohn-Manöver · Tracheotomie · Sprechventil
· Botulinum-Toxin
Key words
Swallowing - dysphagia - aspiration - Mendelsohn-maneuver - tracheostomy - speech
valve - botulinum toxin
Key words
Swallowing · dysphagia · aspiration · Mendelsohn-Maneuver · tracheostomy · speech
valve · botulinum toxin
Key words
Histopathology - Children - Viral infection - Reissner's membrane collapse - Labyrinthitis
- Ototoxicity - Stria vascularis
