Application Of The Ultrasound Examination In Assessing Oropharyngeal Dysphagia In Children With Cerebral Palsy

ObjectiveTo investigate the application value of submental ultrasonography(SUS)in the examination of oropharyngeal swallowing disorder in children with cerebral palsy(CP);to explore a quantitative measurement method with SUS to assess oropharyngeal swallowing function in CP children and to set a severity grading standard of oropharyngeal disphagia using SUS.Materials and MethodsThe research object of this study is children diagnosed as CP with oropharyngeal dysphagia in Children's Rehabilitation Department of the third affiliated hospital of Zhengzhou University from Jan.2016 to Jun.2017.The changes of the tongue thickness and the extent of the hyoid displacement were measured as indexes by submental ultrasonography to explore the relationship between the two indexes and dysphagia.According to inclusion criteria and exclusion criteria,We screened out 45 cases: 25 cases of cerebral palsy with normal swallowing function and 20 children with cerebral palsy who had oropharyngeal dysphagia.The swallowing function of 45 children was evaluated by a pediatric rehabilitation physician,and the children were divided into 3 groups according to the second part of the dysphagia Disorders Survey(DDS)and the disphagia severity scale(DSS).A group has 8 cases with moderate-severe dysphagia;B group has 12 cases with mild dysphagia;C has 25 cases with normal swallowing function.Among A group,5 males,3 females,mean age 5.37±1.06 years;among B group,5 males and 7 females,mean age 6.41±1.16 years;among C group,15 males and 10 females,mean age 6.44±1.98 years.There was no significant difference in age and sex between the groups(P > 0.05).25 cases of C group were measured by two ultrasound doctors of a and b.The measured data were the thickness of the tongue muscle and the amplitude of the hyoid displacement.Each sonographer repeated three times of each data,and recorded the average value,and then sonographer a repeated the steps,two groups of final data were obtained for each index.The 20 cases of A and B were measured by the sonographer of b,and the average value was recorded once.First,data of C was analyzed to calculate the intraclass correlation coefficient(ICC)which was used to evaluate the inter-observer reliability and the test-retest reliability.Second,the group analysis of three groups were analyzed.Third,if the comparison results showed that the difference was statistically significant,the receiver operating characteristic curve(ROC)was used to determine whether it has diagnostic value.If the results were statistical,calculate the Jordan index was true to determine the diagnostic boundary value and its sensitivity and specificity.Inclusion criteria:(1)the diagnostic criteria of CP confirm to Chinese diagnostic criteria of CP of the sixth national conference rehabilitation of children;(2)the type of dysphagia is oropharyngeal dysphagia;(3)ages ranged from 4 to 14 years;(4)conscious,IQ>70 by Wechsler Intelligence Scale for children(WISC),can complete DDS and SUS;(5)agreed to accept the instrument examination of submental ultrasonography.Exclusion criteria:(1)can not complete swallowing;(2)consciousness was not clear,there are high risk of aspiration;(3)there are serious heart disease,liver and kidney function damage;(4)be suffered from acute upper respiratory tract infection,bronchitis,pneumonia and other respiratory diseases;(5)with deformities of oral cavity,pharyngeal,esophagus etc.digestive tract.(6)does not coordinate the examiner.ResultsFirst,the ICC of the changes of tongue muscle thickness showed as follows:the ICC between the two measurements of Dr.a was 0.933,the ICC between a and b was 0.892,and all of them > 0.75(P<0.01).The ICC of hyoid bone displacement showed that the ICC between the two measurements of Dr.a was 0.882,the ICC between a and b was 0.925,all > 0.75(P<0.01).It indicated that the submental ultrasound measurement of the changes of tongue muscle thickness and the extent of the hyoid displacement had a good inter-observer reliability and test-retest reliability.Second,the statistical analysis of the changes of the tongue muscle thickness was that the differences among them was statistically significant(F=6.982,P=0.002).The multiple comparison of them were as follows:the difference between B and C group was not statistically significant(P=0.231).A and B group(P=0.022)?A and C group(P=0.001)had statistical significance.The statistical analysis of the displacements of the hyoid bone was that the differences among them had statistical sense(F=5.843,P=0.006).The multiple comparison of them were as follows:The difference between B and C group was not statistically significant(p=0.781).A and B group(P=0.004)?A and C group(P=0.003)had statistical significance.Third,in the ROC of diagnosis of moderate-severe dysphagia according to the tongue muscle thickness changes,the area under the curve(AUC)=0.853,95%CI(0.699,1.000),P=0.002.By the Youden index,the diagnosis cut-off is muscle thickness change less than 0.95 cm,the sensitivity and specificity respectively were 73% and 87.5%.In the ROC of diagnosis of moderate-severe dysphagia according to the hyoid bone displacement,AUC=0.829,95%CI(0.640,1.000),P=0.004.By the Youden index,the diagnosis cut-off is hyoid bone displacement less than 1.35 cm,the sensitivity and specificity respectively were 86.5% and 75.0%.Conclusion1.The measurement of the changes of tongue muscle thickness and the extent of the hyoid displacement with SUS had a good inter-observer reliability and test-retest reliability.2.The decrease of changes of tongue muscle thickness and hyoid displacements with SUS is useful for diagnostic of moderate-severe oropharyngeal dysphagia in children with cerebral palsy.3.SUS can be used to help to evaluate the oropharyngeal dysphagia by the way of quantitative measurement and it also has good sensitivity and specificity.