Spontaneous Hemorrhage of a Parathyroid Adenoma Into the Mediastinum

ObjectiveTo describe the case of a previously healthy 56-year-old woman, who presented with acute, nontraumatic pain in the left side of the neck and mild dysphagia.MethodsWe report the results of the physical examination, imaging studies, and clinical laboratory studies. In addition, we describe the patient’s hospital course after surgical intervention.ResultsA patient who sought medical attention because of acute, nontraumatic neck pain and dysphagia was subsequently found to have acute extracapsular hemorrhage of a parathyroid adenoma. Computed tomography and magnetic resonance imaging studies revealed a mass effect beginning in the neck and extending into the mediastinum. Surgical exploration of the neck and histopathologic evaluation confirmed the diagnosis of spontaneous rupture of a parathyroid adenoma with associated hemorrhage.ConclusionExtracapsular hemorrhage of a parathyroid adenoma is rare and necessitates a high index of clinical suspicion for diagnosis. This diagnosis should be considered in a patient who presents with acute anemia, hypercalcemia, and a neck mass. (Endocr Pract. 2012;18: e57-e60)     

Dose to swallowing structures and dysphagia in head and neck Intensity Modulated Radiation Therapy – A long term prospective analysis

AimTo analyse the long term swallowing function in head and neck cancer patients and correlate with the dose to midline swallowing structures.BackgroundThe use of concurrent chemo radiation (CRT) as the present standard of care resulted in high rates of early and late toxicities. Dysphagia, aspiration, and xerostomia are early as well as late effects of radiation. Not many studies on the dysphagia scores during radiation and follow-up period have correlated dose to the swallowing structures, hence this study.Materials and MethodsHistologically proven head and neck cancer patients treated with intensity modulated radiation therapy were accrued in this study. The pharyngeal constrictors, larynx and cervical oesophagus were contoured and labelled as midline swallowing structures. The volume of the midline swallowing structures which were outside the PTV was delineated separately and was given a mean dose constraint of 45 Gy. Dysphagia was assessed at baseline, weekly intervals during irradiation and follow-up at six years. The dose to the structures for swallowing was correlated with degree of dysphagia.ResultsThere was a gradual increase in the dysphagia grade during the course of radiation. There was a significant recovery of late dysphagia compared to dysphagia during the completion of radiation therapy in patients who received <45 Gy to the swallowing structures (p < 0.0001).ConclusionGiving a constraint to the swallowing structure and limiting it to <45 Gy resulted in earlier recovery of swallowing function resulted in good physical, mental and social well being of the patients when compared to those who received >45 Gy.     

Radiation induced esophageal adenocarcinoma in a woman previously treated for breast cancer and renal cell carcinoma

ABSTRACT: BACKGROUND: Secondary radiation-induced cancers are rare but well-documented as long-term side effects of radiation in large populations of breast cancer survivors. Multiple neoplasms are rare. We report a case of esophageal adenocarcinoma in a patient treated previously for breast cancer and clear cell carcinoma of the kidney CASE PRESENTATION: A 56 year-old non smoking woman, with no alcohol intake and no familial history of cancer; followed in the National Institute of Oncology of Rabat Morocco since 1999 for breast carcinoma, presented on consultation on January 2011 with dysphagia. Breast cancer was treated with modified radical mastectomy, 6 courses of chemotherapy based on CMF regimen and radiotherapy to breast, inner mammary chain and to pelvis as castration. Less than a year later, a renal right mass was discovered incidentally. Enlarged nephrectomy realized and showed renal cell carcinoma. A local and metastatic breast cancer recurrence occurred in 2007. Patient had 2 lines of chemotherapy and 2 lines of hormonotherapy with Letrozole and Tamoxifen assuring a stable disease. On January 2011, the patient presented dysphagia. Oesogastric endoscopy showed middle esophagus stenosing mass. Biopsy revealed adenocarcinoma. No evidence of metastasis was noticed on computed tomography and breast disease was controlled. Palliative brachytherapy to esophagus was delivered. Patient presented dysphagia due to progressive disease 4 months later. Jejunostomy was proposed but the patient refused any treatment. She died on July 2011 CONCLUSION: we present here a multiple neoplasm in a patient with no known family history of cancers. Esophageal carcinoma is most likely induced by radiation. However the presence of a third malignancy suggests the presence of genetic disorders.     

Basement membrane-like substance in cytologic diagnosis in clear cell adenocarcinoma of the minor salivary gland of the palate. A case report

BACKGROUND: Clear cell adenocarcinoma (CCA) of the minor salivary gland accounts for < 1% of all tumors of the salivary gland. CASE: A 32-year-old woman with a history of papillary carcinoma of the thyroid 1 year earlier complained of pain on the left side of the neck. After a detailed examination, the patient underwent the resection of a tumor located at the palate. Imprint cytology of the tumor revealed cohesive tumor cells of uniform size containing an abundant clear cytoplasm and round nuclei with extra but fine granular chromatin and conspicuous nucleoli. A basement membrane-like substance (BMS) was stained in light green with Papanicolaou staining and was positive for laminin with immunohistochemical staining. Histopathologic analysis confirmed the trabecular or nest-like arrangement of the cells with the clear cytoplasm and BMS substance surrounded by tumor cells, which were positive for laminin and AE1 immunohistochemically. CONCLUSION: Although CCA of the palate is extremely rare, an accurate cytologic diagnosis can be made if the characteristic findings of CCA, including BMS, are imaged.     

Mediastinal pancreatic pseudocyst--a case report and review of the literature

Pancreatic pseudocyst, a common complication of acute or chronic pancreatitis, in rare instances may also extend to the mediastinum. A case of 67-year-old woman presenting with a triad of chest pain, dysphagia, and dyspnea is presented. The patient had an episode of acute alcoholic pancreatitis 1 year before presentation. Chest radiography on admission showed a retrocardiac opacity. Two-dimensional echocardiography revealed an echolucent mass compressing the left atrium. A subsequent upper gastrointestinal series for her dysphagia showed extrinsic compression of the distal esophagus. Finally a definitive diagnosis was made with computed tomography (scan), which revealed a 19 x 12 cm pseudocyst extending from the body of pancreas into the thorax and compressing the esophagus and the cardiac chambers. A mediastinal pseudocyst can cause symptoms due to compression or invasion of surrounding structures. The fluid collection may enlarge slowly and hence the symptoms can be delayed as in our patient. The pseudocyst was successfully treated using endoscopic ultrasound-guided transesophageal drainage. Approximately 50 cases of mediastinal extension of the pancreatic pseudocyst in the world literature are reported. At this time, this is only the second time that successful drainage of a mediastinal pseudocyst using a transesophageal approach under endoscopic ultrasound guidance has been reported. The literature was reviewed for clinical presentation, complications, and available treatment options for mediastinal pancreatic pseudocysts.     

Simultaneous occurrence of medullary and papillary carcinoma of the thyroid gland identified by fine needle aspiration. A case report

BACKGROUND: Fine needle aspiration (FNA) diagnosis of simultaneous medullary and papillary thyroid carcinoma in independent thyroid lobes is exceedingly rare. CASE: A 36-year-old female presented with a one-month history of dysphagia. Thyroid ultrasound revealed a multinodular goiter. She was clinically and biochemically euthyroid. FNA of the right thyroid nodule was consistent with medullary carcinoma, and FNA of the left thyroid lobe was consistent with papillary carcinoma. Immunohistochemistry revealed strong calcitonin and CEA positivity in the right lobe and lack of staining in the left lobe. Conversely, staining for thyroglobulin was negative on the right lobe and positive on the left lobe. CONCLUSION: The patient developed tumors in separate lobes of the thyroid. Immunoreactivity of calcitonin, CEA and thyroglobulin made a sharp distinction between the two tumors. Therefore, we conclude that these tumors were not linked by either embryology or genetics.     

急性脑梗死患者伴吞咽障碍的临床特征及发生卒中相关性肺炎的影响因素分析

摘要 目的：分析急性脑梗死患者伴吞咽障碍的临床特征及发生卒中相关性肺炎（SAP）的影响因素。方法：选取 2019年 10月~2021年 10月本院收治的 190例急性脑梗死患者为调查研究对象,根据患者的洼田饮水试验评分分为吞咽良好组（98例）和吞咽障碍组（92例）,对比两组患者的临床资料,探讨急性脑梗死患者伴吞咽障碍的临床特征。并对 92例吞咽障碍组患者发病期间SAP发生率进行统计,并将患者分为 SAP组和非 SAP组,对两组患者的基础资料、临床资料等进行组间对比分析,并采用单因素分析和多因素 Logistic回归分析探讨影响急性脑梗死吞咽障碍患者发生 SAP的危险因素。结果：吞咽障碍组与吞咽良好组患者的性别、体质指数（BMI）、吸烟史、饮酒史、基础疾病史等比较无统计学差异（P>0.05）,而吞咽障碍组患者的年龄、美国国立卫生院神经功能缺损评分（NIHSS）、梗死面积、梗死部位脑干比例均高于吞咽功能良好组（P<0.05）。92例急性脑梗死伴吞咽障碍患者中有 34例患者发生 SAP,发生率为 36.96%。经单因素分析显示,SAP组与非 SAP组患者的性别、BMI、饮酒史、高血压病史、高脂血病史比较无统计学差异（P>0.05）,而 SAP组患者的年龄、NIHSS评分、吸烟史患者比例、糖尿病史患者比例均高于非 SAP组（P<0.05）。经 Logistic多因素回归分析显示,高龄、高 NIHSS评分、吸烟史、糖尿病史是急性脑梗死伴吞咽障碍并发 SAP发生的独立危险因素（P<0.05,OR＞1）。结论：急性脑梗死患者中高龄、神经功能缺损严重、梗死面积大以及脑干部位梗死患者易出现吞咽功能障碍,且有部分患者会出现 SAP,而高龄、高 NIHSS评分、吸烟史、糖尿病史是诱发 SAP发生的影响因素,值得临床关注。     

头颈部恶性肿瘤患者放疗后吞咽困难的危险因素分析及吞咽功能训练的临床应用价值

摘要 目的：分析头颈部恶性肿瘤（HNC）患者放疗后吞咽困难的危险因素,并观察吞咽功能训练的临床应用效果。方法：选择2020年4月~2022年5月期间在华中科技大学同济医学院附属同济医院接受放疗的HNC患者150例。采用自制调查量表获取患者的一般资料,采用单因素和多因素Logistic分析HNC患者放疗后吞咽困难的危险因素,并观察吞咽功能训练的临床应用效果。结果：本研究中150例HNC患者,放疗后出现吞咽困难的有93例,吞咽困难发生率为62.00%。根据放疗后是否出现吞咽困难将患者分为无吞咽困难组（n=57）和吞咽困难组（n=93）。单因素分析显示,HNC患者放疗后吞咽困难与文化程度、婚姻状况、高血压、糖尿病、高脂血症、居住地、体质量指数无关（P>0.05）,而与年龄、性别、吸烟史、饮酒史、肿瘤分期、肿瘤位置、累积放疗剂量有关（P<0.05）。多因素Logistic回归分析,结果显示：年龄偏大、男性、吸烟史、饮酒史、肿瘤分期为III期、肿瘤位置为颈部肿瘤、累积放疗剂量偏高是HNC患者放疗后吞咽困难的危险因素（P<0.05）。HNC患者干预1个月后、干预2个月后安德森吞咽困难量表（MDADI）评分较干预前下降,功能性经口摄食量表（FOIS）评分较干预前升高（P<0.05）。结论：HNC患者放疗后吞咽困难的发生率较高,年龄、性别、吸烟史、饮酒史、肿瘤分期、肿瘤位置、累积放疗剂量等均是其影响因素。HNC患者放疗期间给予吞咽功能训练,可有效改善患者的吞咽状况。     

Effects of reversible cold block of face primary somatosensory cortex on orofacial movements and related face primary motor cortex neuronal activity

Our previous studies have revealed that face primary somatosensory cortex (SI) as well as face primary motor cortex (MI) play important roles in the control of orofacial movements in awake monkeys, and that both face MI and face SI neurons may have an orofacial mechanoreceptive field and show activity related to orofacial movements. Since it is possible that the movement-related activity of face MI neurons could reflect movement-generated orofacial afferent inputs projecting to face MI via face SI, the present study used reversible cold block-induced inactivation of the monkey's face SI to determine if face MI neuronal activity related to a trained tongue-protrusion task, chewing or swallowing was dependent on the functional integrity of the ipsilateral face SI and if inactivation of face SI affects orofacial movements. The effects of face SI cold block were tested on chewing, swallowing and/or task-related activity of 73 face MI neurons. Both task and chewing and/or swallowing-related activity of most face MI neurons was independent of the functional integrity of the ipsilateral face SI since SI cold block affected the movement-related activity in approximately 25% of the neurons. Similarly, unilateral cold block of SI had very limited effects on the performance of the task and chewing, and no effect on the performance of swallowing. These findings suggest that movement-induced reafferentation via face SI may not be a significant factor in accounting for the activity of the majority of ipsilateral face MI neurons related to trained movements, chewing and swallowing.     

Effects of reversible cold block of face primary somatosensory cortex on orofacial movements and related face primary motor cortex neuronal activity

Our previous studies have revealed that face primary somatosensory cortex (SI) as well as face primary motor cortex (MI) play important roles in the control of orofacial movements in awake monkeys, and that both face MI and face SI neurons may have an orofacial mechanoreceptive field and show activity related to orofacial movements. Since it is possible that the movement-related activity of face MI neurons could reflect movement-generated orofacial afferent inputs projecting to face MI via face SI, the present study used reversible cold block-induced inactivation of the monkey's face SI to determine if face MI neuronal activity related to a trained tongue-protrusion task, chewing or swallowing was dependent on the functional integrity of the ipsilateral face SI and if inactivation of face SI affects orofacial movements. The effects of face SI cold block were tested on chewing, swallowing and/or task-related activity of 73 face MI neurons. Both task and chewing and/or swallowing-related activity of most face MI neurons was independent of the functional integrity of the ipsilateral face SI since SI cold block affected the movement-related activity in approximately 25% of the neurons. Similarly, unilateral cold block of SI had very limited effects on the performance of the task and chewing, and no effect on the performance of swallowing. These findings suggest that movement-induced reafferentation via face SI may not be a significant factor in accounting for the activity of the majority of ipsilateral face MI neurons related to trained movements, chewing and swallowing.     

Recurrent Acute Suppurative Thyroiditis Attributable to a Piriform Sinus Fistula in an Adult

ObjectiveTo report a case of recurrent acute suppurative thyroiditis (AST) caused by a piriform sinus fistula (PSF).MethodsWe review the related literature and describe the clinical presentation, diagnostic evaluation, and management of a patient with recurrent AST due to PSF.ResultsA 50-year-old woman presented with recurrent episodes of pain and swelling in the left anterior neck area and odynophagia. The initial episode, 1 year previously, lasted for 1 month, and her condition improved with a short course of prednisone. Subsequently, the neck pain recurred and extended upward to both sides of the neck. She was suspected of having thyroiditis and was treated with prednisone for 6 weeks, but the symptoms persisted. Physical examination showed tenderness and induration of the skin over the left lobe of the thyroid. Ultrasonography disclosed an ill-defined solid-cystic area in the left thyroid lobe. Fine-needle aspiration cytology revealed acute inflammation, consistent with an infected cyst. A computed tomographic scan of the neck showed obscuration of the fat planes involving the left strap musculature and evidence suggestive of microabscesses. Prolonged intravenous antibiotic treatment ultimately alleviated the symptoms. Direct laryngoscopy revealed a fistula extending anteriorly from the apex of the piriform sinus. The patient underwent complete fistulectomy and left thyroid lobectomy and was asymptomatic on followup.ConclusionPSF should be suspected as a cause of recurrent AST. Absence of fever, toxemia, and local erythema does not rule out the condition. Unresponsiveness to corticosteroid therapy in thyroiditis should suggest the diagnosis. Complete fistulectomy and resection of the involved thyroid lobe result in permanent cure. (Endocr Pract. 2007;13:662-666)     

Hyperbaric oxygen therapy for radiation-induced brachial plexopathy,a case report and literature review

AimTo report a case of radiation-induced brachial plexopathy (RIBP) with significant radiographic and clinical improvement after a course of hyperbaric oxygen (HBO).BackgroundRIBP is a rare complication after radiotherapy to the neck and axilla. There are no standard treatment options, with empirical use pharmacotherapy being predominately used, which has had mixed results.HBO is efficacious for the treatment of other severe radiation-induced side effects, however, its benefit in RIBP has conflicting reports.Case PresentationA 45-year-old male, with a 33 pack-year smoking history, presented with a 6-month history of a progressive left neck mass. The final diagnosis was unknown primary squamous cell carcinoma of the head and neck. He received intensity-modulated radiation therapy (IMRT) with 70 Gy prescribed to the gross tumor volume (PTV HR) and 56 Gy to the oropharynx, nasopharynx, and bilateral lymphatics (PTV SR) in 35 daily fractions with three cycles of concurrent cisplatin at 100 mg/m².Fifteen months following therapy completion, the patient began to endorse symptoms of left brachial plexopathy. Decadron was prescribed for 2 weeks, trental and vitamin E for 6 months, and HBO. The patient returned for follow-up 2 months after completing 30 dives of HBO at 2.4 atmospheres for 2 hours per session. He reported pain resolution and full range of motion of his left arm.ConclusionsThe best management strategy of RIBP is prevention by reducing total RT doses and close follow-up. However, when RIBP occurs, we recommend treatment with HBO therapy, steroids, trental, and vitamin E as tolerable.     

A Case Study of a Patient with Gliosarcoma with an Extended Survival and Spinal Cord Metastases

Gliosarcoma is a rare brain tumor consisting of both glial and mesenchymal components. Metastatic gliosarcoma is rare; however, here we report a 31-year-old Chinese woman with cranial gliosarcoma metastatic to the liver, lymph nodes and the spinal cord. Initially, the patient presented with dizziness, headache and vomiting and after surgery and histological examination, was diagnosed with cranial gliosarcoma. The patient was treated with surgical resection followed by chemotherapy and radiotherapy. Three years after completing treatment, the patient again presented with similar symptoms with the addition of a seizure. Test revealed recurrence of the gliosarcoma, and the same treatment was prescribed. Three years after treatment completion, the patient again presented with dizziness and headache. Masses at the right temple and in the right side of the neck were found. Tumors were surgically removed from the brain, skull, scalp and neck, the latter three diagnosed as metastatic gliosarcomas. The patient received both chemotherapy and radiotherapy following resection. One month after treatment, bone scans revealed possible metastasis in the right skull, lumbar and left ileum, soft neck tissue, lungs, collarbone, humeri, vertebrae, liver and abdominal lymph nodes. No further therapy was recommended due to the poor condition of the patient. The patient died 5 months later.     

Phoniatrics in the rehabilitation for head and neck cancer

The aim of treating head and neck cancer is to eliminate the tumor and save functions as much as possible. Despite all efforts the vital (swallowing) and communicative (phonation, articulation) functions can be injured. The treatment of dysphagia is the most important in the rehabilitation, because it can lead to fatal complications: aspiration pneumonia (for example aspiration of saliva), dehydration, malnutrition. According to the localization of the lesion we distinguish oropharyngeal and esophageal dysphagia. The aspiration may be pre-, intra- and post-deglutition. The aspiration without coughing is called silent aspiration which is mainly seen in neurogenic dysphagia, but can also happen in head and neck cancer patients. There are different possibilities to compensate the failing functions in the phoniatric rehabilitation. The swallowing therapy includes causal, compensatory and dietary strategies. In addition to the swallowing therapy the treatment of communicative dysfunctions with articulation exercises will also improve the quality of life of the patients.     

Suppurative thyroiditis caused by Salmonella enteritidis

Bacterial thyroiditis is a rare disease, and one of which the clinical symptoms and signs are frequently misleading. On the other hand, prompt diagnosis is crucial for successful treatment. We report the case of an 82 year-old man with diabetes mellitus type 2 and a history of steroid treatment who presented with severe odynophagia and dysphagia associated with fever, chills, sore throat and right ear pain. Based on the clinical picture, radiological studies, thyroid cytology, blood and thyroid aspirate culture, suppurative thyroiditis caused by Salmonella enteritidis was diagnosed. The patient was successfully treated with antibiotics and surgical drainage.     

An investigation of the simultaneously recorded occlusal contact and surface electromyographic activity of jaw-closing muscles for patients with temporomandibular disorders and a scissors-bite relationship

Surface electromyographic (SEMG) activity of the masseter and anterior temporalis (TA) muscles has been reported to be associated with occlusion and orofacial pain. However, our recent report did not reveal an association between the side of orofacial pain and the side showing higher or lower level of SEMG activity of masseter or TA. The present purpose was to re-test this association in patients who had unilateral scissors-bite relationship. Thirty-two unilateral scissors-bite femalepatients complaining of unilateral orofacial pain (n = 15) or TMJ sounds (n = 17) were enrolled to simultaneously record contacts, force distribution of occlusion, and SEMG activity of masseter and TA during centric maximal voluntary clenching (MVC). The results indicated that neither orofacial pain nor the TMJ sounds had an association with the masseter’s SEMG values, while scissors-bite had (P < 0.05). A lower SEMG value for masseter was found on the scissors-bite side where there was a smaller number of contacts and a lower biting force distribution (P < 0.05). No such association was revealed in TA. In conclusion, in patients with unilateral TMD symptom(s) and scissors-bite, the jawclosing muscles’ SEMG activity during centric MVC was associated with the scissors-bite rather than the symptoms of orofacial pain or TMJ sounds.     

Trait anxiety affects the orofacial nociceptive response in rats

The aims of the present study were to assess the influence of: a) trait anxiety on orofacial pain; and b) orofacial pain on state anxiety. Forty-four rats were initially exposed to the free-exploratory paradigm for the evaluation of their anxiety profiles. In accordance to the parameter "Percentage of time in the novel side", the animals were considered as presenting high or low levels of trait anxiety when presenting values below the 1st quartile, or above the 3rd quartile, respectively. A week later, formalin-1.5% was injected into the upper lip of each animal. The behavioural nociceptive response, characterized by increased orofacial rubbing (OR), was quantified for 30 minutes, as follows: Total time OR (0-30 minutes: total pain), 1st phase OR (0-6 minutes: neurogenic pain), and 2nd phase OR (12-30 minutes: inflammatory pain). Immediately after this test, but still under the effect of formalin, the rats were submitted to the Elevated Plus-maze test (EPM). The results showed that the high trait anxiety individuals presented higher frequency of OR than the low trait anxiety ones, except during the neurogenic pain period. However, no correlation was found between OR frequency and levels of state anxiety presented on the EPM. In conclusion, the animals presenting higher anxiety profiles were the most susceptible to orofacial pain, nevertheless, orofacial pain did not influence state anxiety.     

A rare case of melanotic hyperpigmentation of the tongue secondary to radiotherapy

Melanotic hyperpigmentation of the mucosa secondary to radiotherapy is a rare occurrence. It is a diagnosis of exclusion. Literature review has identified only two case reports published to date. We present a case of a patient treated at our institution. An 18-year-old male patient of Nigerian descent underwent radical radiotherapy (36 Gy in 18 daily fractions) to his right neck for paediatric type follicular lymphoma over a period of four weeks. He developed hyperpigmented tongue lesions during the third week of radiotherapy. There was no associated tongue discomfort, inflammation, infection, or pigmentation change elsewhere in the oral mucosa. Review of medications and past medical history did not demonstrate any potential contributing factors. Full blood count and biochemistry, morning cortisol levels and coagulation screen were all normal apart from mild neutropenia and lymphopenia. His oral cavity received a mean dose of 16.4 Gy, with the right side of his tongue receiving up to 37.5 Gy as this was within the planning target volume (PTV). He had an excellent response to radiotherapy and remains in remission. The tongue lesions resolved spontaneously 3 months post treatment.     

Altered alignment of the shoulder girdle and cervical spine in patients with insidious onset neck pain and whiplash-associated disorder

Clinical theory suggests that altered alignment of the shoulder girdle has the potential to create or sustain symptomatic mechanical dysfunction in the cervical and thoracic spine. The alignment of the shoulder girdle is described by two clavicle rotations, i.e, elevation and retraction, and by three scapular rotations, i.e., upward rotation, internal rotation, and anterior tilt. Elevation and retraction have until now been assessed only in patients with neck pain. The aim of the study was to determine whether there is a pattern of altered alignment of the shoulder girdle and the cervical and thoracic spine in patients with neck pain. A three-dimensional device measured clavicle and scapular orientation, and cervical and thoracic alignment in patients with insidious onset neck pain (IONP) and whiplash-associated disorder (WAD). An asymptomatic control group was selected for baseline measurements. The symptomatic groups revealed a significantly reduced clavicle retraction and scapular upward rotation as well as decreased cranial angle. A difference was found between the symptomatic groups on the left side, whereas the WAD group revealed an increased scapular anterior tilt and the IONP group a decreased clavicle elevation. These changes may be an important mechanism for maintenance and recurrence or exacerbation of symptoms in patients with neck pain.     

Cortical processing of swallowing in ALS patients with progressive dysphagia--a magnetoencephalographic study

Amyotrophic lateral sclerosis (ALS) is a rare disease causing degeneration of the upper and lower motor neuron. Involvement of the bulbar motor neurons often results in fast progressive dysphagia. While cortical compensation of dysphagia has been previously shown in stroke patients, this topic has not been addressed in patients suffering from ALS. In the present study, we investigated cortical activation during deglutition in two groups of ALS patients with either moderate or severe dysphagia. Whole-head MEG was employed on fourteen patients with sporadic ALS using a self-paced swallowing paradigm. Data were analyzed by means of time-frequency analysis and synthetic aperture magnetometry (SAM). Group analysis of individual SAM data was performed using a permutation test. We found a reduction of cortical swallowing related activation in ALS patients compared to healthy controls. Additionally a disease-related shift of hemispheric lateralization was observed. While healthy subjects showed bilateral cortical activation, the right sensorimotor cortex was predominantly involved in ALS patients. Both effects were even stronger in the group of patients with severe dysphagia. Our results suggest that bilateral degeneration of the upper motor neuron in the primary motor areas also impairs further adjusted motor areas, which leads to a strong reduction of 'swallowing related' cortical activation. While both hemispheres are affected by the degeneration a relatively stronger activation is seen in the right hemisphere. This right hemispheric lateralization of volitional swallowing observed in this study may be the only sign of cortical plasticity in dysphagic ALS patients. It may demonstrate compensational mechanisms in the right hemisphere which is known to predominantly coordinate the pharyngeal phase of deglutition. These results add new aspects to our understanding of the pathophysiology of dysphagia in ALS patients and beyond. The compensational mechanisms observed could be relevant for future research in swallowing therapies.