Glottal closure during the pharyngeal phase of swallowing is one of the important steps in protecting the airway. Generally, it is believed that any deficiency in this process can lead to laryngeal penetration and aspiration. This study investigated the incidence of laryngeal penetration and aspiration among 44 patients with glottal closure insufficiencies that were referred for voice and swallowing evaluation to our institution. The videostroboscopy and 3 oz water swallow test were performed for all of the patients and dysphagic patients were screened and referred for videofluoroscopy. Overall, 15.90% of patients demonstrated signs of laryngeal penetration (13.63%) and aspiration (2.27%). The patients with the pattern of incomplete closure illustrated the highest percentage of penetration-aspiration (21.73%, 4.34%) among other GCI patterns. Thus, early interventions for these patients’ swallowing condition seem necessary. 1. Introduction While swallowing is one of the most critical requirements of every human, the affected swallow could be the source of pain, nutritional incompetency, and loss of health [1]. Any deficiency in the safety of swallowing can lead to laryngeal penetration and aspiration, and these outcomes can result in adverse health consequences such as pneumonia and even death [2, 3]. One of the protective mechanisms in the swallowing process is glottal closure. Laryngeal closure will initiate with arytenoids adduction, glottal closure, and respiratory apnea and will be accompanied with laryngeal elevation and epiglottis inversion [4, 5]. One of the issues that can lead to incomplete airway closure during swallowing is glottal closure insufficiency (GCI). Belafsky and his colleagues defined GCI as a “form of laryngeal hypofunction during which the closed phase of phonation, which is normally 50% of the cycle of vibration, is 45% or less” [6]. With regard to the form of glottis closure, GCI can be observed in one of the six configurations: (I) anterior chink, (II) posterior chink, (III) irregular, (IV) spindle, (V) hourglass, and (VII) incomplete closure (Figure 1) [7]. Figure 1: Different pattern of GCI. Different patterns of glottal closure insufficiency (GCI): (a) anterior chink, (b) posterior chink, (c) irregular, (d) spindle (e), hourglass, and (f) incomplete closure. According to Colton study, “An anteriorly remarkable opening of the vocal folds is named anterior chink. If several contact points with openings in between exist along the vocal folds, it refers to irregular. When the folds close posteriorly and anteriorly except in
References
[1]
A. Perlman, Deglutition and Its Disorders: Anatomy, Physiology, Clinical Diagnosis, and Management, Singular Publishing Group, London, UK, 1997.
[2]
P. Clavé, R. Terré, M. de Kraa, and M. Serra, “Approaching oropharyngeal dysphagia,” Revista Espanola de Enfermedades Digestivas, vol. 96, no. 2, pp. 119–131, 2004.
[3]
P. Clavé, A. Verdaguer, and V. Arreola, “Oral-pharyngeal dysphagia in the elderly,” Medicina Clinica, vol. 124, no. 19, pp. 742–748, 2005.
[4]
J. A. Logemann, P. J. Kahrilas, J. Cheng et al., “Closure mechanisms of laryngeal vestibule during swallow,” American Journal of Physiology, vol. 262, no. 2, pp. G338–G344, 1992.
[5]
R. Shaker, W. J. Dodds, R. O. Dantas, W. J. Hogan, and R. C. Arndorfer, “Coordination of deglutitive glottic closure with oropharyngeal swallowing,” Gastroenterology, vol. 98, no. 6, pp. 1478–1484, 1990.
[6]
P. C. Belafsky, G. N. Postma, T. R. Reulbach, B. W. Holland, and J. A. Koufman, “Muscle tension dysphonia as a sign of underlying glottal insufficiency,” Otolaryngology, vol. 127, no. 5, pp. 448–451, 2002.
[7]
M. Andrews, Manual of Voice Treatment, Thomson Delmar Learning, Canada, 2006.
[8]
R. H. Colton, Understanding Voice Problems, a physiological Perspective for Diagnosis and Treatment, Lippincott Williams & Wilkins, Baltimore, Md, USA, 2011.
[9]
E. J. Damrose and G. S. Berke, “Advances in the management of glottic insufficiency,” Current Opinion in Otolaryngology and Head and Neck Surgery, vol. 11, no. 6, pp. 480–484, 2003.
[10]
P. W. Flint, L. L. Purcell, and C. W. Cummings, “Pathophysiology and indications for medialization thyroplasty in patients with dysphagia and aspiration,” Otolaryngology, vol. 116, no. 3, pp. 349–354, 1997.
[11]
G. Y. Shaw and J. P. Searl, “Electroglottographic and acoustic changes following type I thyroplasty or autologous fat injection,” Annals of Otology, Rhinology and Laryngology, vol. 110, no. 11, pp. 1000–1006, 2001.
[12]
T.-J. Fang, H. Y. Li, F. C. Tsai, and I. H. Chen, “The role of glottal gap in predicting aspiration in patients with unilateral vocal paralysis,” Clinical Otolaryngology and Allied Sciences, vol. 29, no. 6, pp. 709–712, 2004.
[13]
R. F. Heitmiller, E. Tseng, and B. Jones, “Prevalence of aspiration and laryngeal penetration in patients with unilateral vocal fold motion impairment,” Dysphagia, vol. 15, no. 4, pp. 184–187, 2000.
[14]
S. B. Leder and D. A. Ross, “Incidence of vocal fold immobility in patients with dysphagia,” Dysphagia, vol. 20, no. 2, pp. 163–167, 2005.
[15]
B. Ollivere, K. Duce, G. Rowlands, P. Harrison, and B. J. O'Reilly, “Swallowing dysfunction in patients with unilateral vocal fold paralysis: aetiology and outcomes,” Journal of Laryngology and Otology, vol. 120, no. 1, pp. 38–41, 2006.
[16]
J. Pavithran and J. R. Menon, “Unilateral vocal cord palsy: an etiopathological study,” International Journal of Phonosurgery and Laryngology, vol. 1, no. 1, pp. 5–10, 2011.
[17]
A. Tabaee, T. Murry, A. Zschommler, and R. B. Desloge, “Flexible endoscopic evaluation of swallowing with sensory testing in patients with unilateral vocal fold immobility: incidence and pathophysiology of aspiration,” Laryngoscope, vol. 115, no. 4, pp. 565–569, 2005.
[18]
D. M. Suiter and S. B. Leder, “Clinical utility of the 3-ounce water swallow test,” Dysphagia, vol. 23, no. 3, pp. 244–250, 2008.
[19]
J. C. Rosenbek, J. A. Robbins, E. B. Roecker, J. L. Coyle, and J. L. Wood, “A penetration-aspiration scale,” Dysphagia, vol. 11, no. 2, pp. 93–98, 1996.
[20]
A. Barikroo and P. M. Lam, “Comparing the effects of rehabilitation swallowing therapy versus functional neuromuscular electrical stimulation therapy in an encephalitis patient: a case study,” Dysphagia, vol. 26, no. 4, pp. 418–423, 2011.
