Pharyngeal mis-sequencing in dysphagia: Characteristics, rehabilitative response, and etiological speculation

Objective: Clinical data are submitted as documentation of a pathophysiologic feature of dysphagia termed pharyngeal mis-sequencing and to encourage clinicians and researchers to adopt more critical approaches to diagnosis and treatment planning. Background: Recent clinical experience has identified a cohort of patients who present with an atypical dysphagia not specifically described in the literature: mis-sequenced constriction of the pharynx when swallowing. As a result, they are unable to coordinate streamlined bolus transfer from the pharynx into the esophagus. This mis-sequencing contributes to nasal redirection, aspiration, and, for some, the inability to safely tolerate an oral diet. Method: Sixteen patients (8 females, 8 males), with a mean age of 44 years (range = 25-78), had an average time post-onset of 23 months (range = 2-72) at initiation of intensive rehabilitation. A 3-channel manometric catheter was used to measure pharyngeal pressure. Results: The average peak-to-peak latency between nadir pressures at sensor-1 and sensor-2 was 15 ms (95% Cl, 2 to 33 ms), compared to normative mean latency of 239 ms (95% Cl, 215 to 263 ms). Rehabilitative responses are summarized, along with a single detailed case report. Conclusion: It is unclear from these data if pharyngeal mis-sequencing is (i) a pathological feature of impaired motor planning from brainstem damage or (ii) a maladaptive compensation developed in response to chronic dysphagia. Future investigation is needed to provide a full report of pharyngeal mis-sequencing, and the implications on our understanding of underlying neural control of swallowing. (C) 2014 Elsevier B.V. All rights reserved.