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

• Clinical series of an atypical dysphagia termed pharyngeal mis-sequencing
• Rehabilitative responses summarized, along with a single detailed case report
• Unclear if mis-sequencing is feature of brain damage or maladaptive compensation
• Aim to encourage more critical approaches to evaluation and treatment planning
• Implications for understanding of underlying neural control of swallowing

ObjectiveClinical 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.BackgroundRecent 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.MethodSixteen 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.ResultsThe average peak-to-peak latency between nadir pressures at sensor-1 and sensor-2 was 15 ms (95% CI, − 2 to 33 ms), compared to normative mean latency of 239 ms (95% CI, 215 to 263 ms). Rehabilitative responses are summarized, along with a single detailed case report.ConclusionIt 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.