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.