Chronische Schluckstörungen. Teil 2: Therapie

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

Literatur (Teil 1und 2)

• 1 Baumann I, Rodegerdts E, Rodriquez Jorge J, Dammann F. Die Messung der oropharyngealen Schluckeffizienz bei Oropharynxtumoren. 5. Kongress der Spanisch-Deutschen Gesellschaft für Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie, 19. - 21. Juni 2003 in Fulda.  Laryngo-Rhino-Otol. 2003;  82 S859-S860
• 2 Bartholome G. Physiologie des Schluckvorgangs.  Sprache Stimme Gehör. 1999;  23 3-6
• 3 Bartholome G. Funktionelle Dysphagietherapie (FDT).  Sprache Stimme Gehör. 1999;  23 35-44
• 4 Bigenzahn W, Denk D M. Oropharyngeale Dysphagien. Ätiologie, Klinik, Diagnostik und Therapie von Schluckstörungen. Stuttgart; Thieme 1999
• 5 Ding R, Larson C R, Logemann J A, Rademaker A W. Surface electromyographic and electroglottographic studies in normal subjects under two swallowing conditions: normal and during the Mendelsohn-maneuver.  Dysphagia. 2002;  17 1-12
• 6 Dobrinski W. Radiologische Diagnostik von Schluckstörungen.  Sprache Stimme Gehör. 1999;  23 24-28
• 7 Hacki T, Kramer H, Kleinjung C, Pérez-Alvarez C, Schmid J. Endoskopische Mehrfarben-Schluckuntersuchung.  Laryngo-Rhino-Otol. 2000;  79 335-340
• 8 Hannig C, Wuttge-Hannig A, Hess U. Analyse und radiologisches Staging des Typs und Schweregrades einer Aspiration.  Radiologe. 1995;  35 741-746
• 9 Logemann J A. Dysphagia: Basic assessment and management issues. In: Johnson AF, Jacobson BH (Hrsg.) Medical Speech-language Pathology. A Practitioner’s Guide. New York; Thieme 1998: 17-37
• 10 Logemann J A. Efficiacy, outcomes, and cost effectiveness in dysphagia. In: Frattali CM (Hrsg) Measuring Outcomes in Speech-language Pathology. New York; Thieme 1998: 321-333
• 11 Nathadwarawala K M, Nicklin J, Wiles C M. A timed test of swallowing capacity for neurological patients.  J Neurol Neurosurg Psychiat. 1992;  55 822-825
• 12 Schneider I, Pototschnig C, Thumfart W F, Eckel H E. Treatment of dysfunction of the cricopharyngeal muscle with Botulinum A Toxin: Introduction of a new, noninvasive method.  Ann Otol Rhinol Laryngol. 1994;  103 31-35
• 13 Schröter-Morasch H. Schweregradeinteilung der Aspiration bei Patienten mit Schluckstörung. In: Gross M (Hrsg.) Aktuelle phoniatrisch-pädaudiologische Aspekte 1995. Berlin; Renate-Gross-Verlag 1996: 145-146
• 14 Schröter-Morasch H. Ätiologie und klinische Manifestation von Schluckstörungen.  Sprache Stimme Gehör. 1999;  23 11-15
• 15 Schröter-Morasch H. Phoniatrische Diagnostik und Therapieevaluation bei Dysphagie.  Sprache Stimme Gehör. 1999;  23 16-23
• 16 Schröter-Morasch H. Medizinische Basisversorgung von Patienten mit Schluckstörungen. Trachealkanülen - Sondenernährung. In: Bartolome G, Buchholz DW, Feussner H, Hannig C, Neumann S, Prosiegel M, Schröter-Morasch H, Wuttge-Hannig A (Hrsg) Schluckstörungen. Diagnostik und Rehabilitation. 2. Aufl. München; Urban und Fischer 1999
• 17 Schröter-Morasch H. Dysphagie mit vitaler Bedrohung und psychosozialer Beeinträchtigung als Teilbereich der Phoniatrie und Pädaudiologie. 20. Jahrestagung der Deutschen Gesellschaft für Phoniatrie und Pädaudiologie, 12. - 14. September 2003 in Rostock, Online-Publikation der German Medical Science: www.egms.der/de/meetings/dgpp2003/03dgpp039.shtml.  . ; 
• 18 Seidl R O, Nusser-Müller-Busch R, Ernst A. Evaluation eines Untersuchungsbogen zur endoskopischen Schluckuntersuchung.  Sprache Stimme Gehör. 2002;  26 28-36
• 19 Silbergleit A K, Basha M. Speech-language pathology in the intensive care unit. In: Johnson AF, Jacobson BH (Hrsg) Medical Speech-language Pathology. A Practitioner’s Guide. New York; Thieme 1998: 65-95
• 20 Walther E K. Rationale Dysphagiediagnostik.  Laryngo-Rhino-Otol. 1993;  72 459-460
• 21 Weber R, Mai R, Draf W. Was bringt die chirurgische Therapie von Schluckstörungen nach dem Denecke-Konzept?.  HNO. 2000;  48 281-286