Early and accurate evaluation and intervention are essential and the
province of all clinicians
R. Becker, A. Friedrich, A. Nagel, E.
Steinhagen-Thiessen: Funktionelle Dysphagietherapie: Implikationen für die
Nahrungsaufnahme European Journal of Geriatics 5 (2003) No. 3
Abstract:
Die
Dysphagie ist ein häufiges Krankheitsbild in geriatrischen Kliniken. Die
funktionelle Dysphagietherapie hat die Aktivierung und Wiederherstellung der
beeinträchtigten Funktionen bei der Nahrungsaufnahme und/oder die Vermittlung
von Techniken und Strategien zur Kompensation der Störung zum Ziel. Es soll
eine sichere und selbständige Nahrungsaufnahme erreicht bzw. erhalten werden.
Die vorliegende Studie untersucht mit einem Bedside-Screening an einer
Stichprobe von 100 Patienten: Welche Veränderungen werden bei der
Nahrungsaufnahme über das Therapieprogramm erzielt und haben kognitive und
kommunikative Störungen einen Einfluss auf das Therapieergebnis.? Mit einem
Prä- und Postdesign konnte eine signifikante Verbesserung der
Schluckfunktion nach Therapie nachgewiesen werden . 21% der Patienten
erreichten sogar normale Funktionen bei der Nahrungsaufnahme. Sprachliche
und kognitive Leistungen (gemessen am Mini-Mental State und Token-Test) wiesen
keinen Zusammenhang mit den Therapieergebnissen auf.
Ramsey DJ, Smithard DG, Kalra L. Stroke. 2003 May;34(5):1252-7. Epub
2003 Apr 03 Early assessments of
dysphagia and aspiration risk in acute stroke patients.
Abstract:
BACKGROUND AND PURPOSE: Dysphagia is common after stroke and is a marker of
poor prognosis. Early identification is important. This article reviews the
merits and limitations of various assessment methods available to clinicians.
METHODS: An electronic database search was performed of MEDLINE, EMBASE, and
the Cochrane database using such terms as stroke, aspiration, dysphagia, and
assessment; extensive manual searching of articles was also conducted. RESULTS:
Bedside tests are safe, relatively straightforward, and easily repeated but
have variable sensitivity (42% to 92%), specificity (59% to 91%), and
interrater reliability (kappa=0 to 1.0). They are also poor at detecting
silent aspiration. Videofluoroscopy gives anatomic and functional information
and allows testing of therapeutic techniques. However, swallowing is assessed
under ideal conditions that are different from clinical settings, and
reliability is often poor (kappa=0 to 0.75) in the absence of assessor
training. Fiberoptic endoscopy allows swallow assessment and sensory testing
but requires specialized staff and equipment. Oxygen desaturation during
swallowing may be predictive of aspiration (sensitivity, 73% to 87%;
specificity, 39% to 87%) but is more useful in combination with bedside
testing than in isolation. Other methods of swallow testing are invasive and
require specialized staff and equipment. CONCLUSIONS: Although bedside tests
remain an important early screening tool for dysphagia and aspiration risk,
further refinements are needed to improve their accuracy.
K.F. Fasano, J.M. Liss, J.L. Gase, K.G.M.Gerritsen and R.C.Katz:
"Effects of Mechanical, Cold, Gustatory and Combined Stimulation to the Human
Anterior Faucial Pillars" Dysphagia 18, No. 1, 2003 wirklich
interessante Studie zu unserer täglichen Arbeit mit thermo-taktiler
Stimulation - Ergebnis ist wirklich erstaunlich lohnenswert!!!
ABSTRACT:
Tactile-Thermal Application (TTA) is a therapy technique designed to
enhance the swallowing response in persons with dysphagia. In this study, TTA
was broken down into each component stimulus (i.e., Cold, Mechanical,
Gustatory), and all combinations thereof, to study the effects of each
condition on measurable parameters of the normal human swallow response. Using
surface electromyography (EMG), latency to swallow-specific activity and
duration of submental EMG activity were measured to examine the following
questions: (1) Are there stimulus-dependent differences in onset latencies and
contraction durations of the submental muscle activity? (2) Which stimulus
components are responsible for this response? (3) How long do the effects of
stimulation last on the response? (4) Are there response differences according
to age and gender? Between-subjects multivariate analysis of variance showed
that the main effects for Treatment, Gender, and Age were significant. Latency
to swallow-specific activity was significantly shorter following Mechanical +
Cold + Gustatory condition compared to No Stimulation. The effect of
stimulation on the swallow response lasted for only one swallow.
Gloria Chi-Fishman, Barbara C Sonies : Effects of Systematic
Bolus Viscosity and Volume Changes on Hyoid Movement Kinematics Dysphagia
(4) 278-287 (2002)
Abstract:
Using ultrasonography with head and transducer stabilization, this study
examined the effects of maximally controlled, systematic changes in bolus
viscosity (thin juice-like, 7 cP; nectar-like, 243–260 cP; honey-like, 724–759
cP; spoon-thick, 2760–2819 cP) and volume (5, 10, 20, 30 cc) on hyoid
kinematics in 31 healthy subjects (16 male, 15 female) in three age groups
(20–39, 40–59, 60–79 years). Frame-by-frame hyoid displacements were tracked
from digitized images of 612 swallows. Measures of movement durations, maximal
amplitudes, total distances, and peak velocities were subjected to repeated
measures multivariate analyses of variance with viscosity, volume, age, and
gender as factors. Results showed that (1) spoon-thick swallows had the
greatest preswallow gesture and total movement durations; (2) larger-volume
swallows had significantly greater maximal amplitudes, forward peak velocity,
and total vertical distance; (3) older subjects had longer start-to-max
duration (though shorter preswallow gesture and total movement durations),
greater maximal vertical amplitude, longer total vertical distance, and
greater backward peak velocity than younger subjects; (4) males had greater
values for all kinematic parameters except preswallow gesture, hyoid-at-max,
and max-to-end durations. The results illustrate the importance of examining
the interrelations among kinematic variables to better understand task
accommodation and motor control strategies. The evidence also supports the
concept of suprahyoid–infrahyoid functional adaptation and compensation in the
healthy elderly.
Susan E Langmore, Kimberly A Skarupski, Pil S Park, Brant E Fries :
Predictors of Aspiration Pneumonia in Nursing Home Residents Dysphagia
(4) 298-307 (2002)
Abstract:
Aspiration pneumonia is a serious problem for the elderly
institutionalized person, often requiring transfer to a hospital and a lengthy
stay there. It is associated with a high mortality rate and is very costly to
the health care system. The current study sought to determine the key
predictors of aspiration pneumonia in a nursing home population with the hope
that health care providers could identify those residents at highest risk and
focus more efforts on prevention of this serious disease. A cross-sectional,
retrospective analysis was done, using the Minimum Data Set (MDS) nursing home
assessment data for three states (New York, Mississippi, Maine) from 1993 to
1994 (N = 102,842). Nursing home residents were aged 65+. Standardized MDS
summary scales and their component items were used, including: the Activities
of Daily Living (ADL) scale, the cognitive performance scale (CPS), and the
Resource Utilization Groups (RUGs). Results of these analyses showed the
prevalence of pneumonia among this population was 3% (n = 3118). Results from
the logistic regression models indicated 18 significant predictors of
aspiration pneumonia. The strongest to weakest predictors of pneumonia were,
respectively, suctioning use, COPD, CHF, presence of feeding tube, bedfast,
high case mix index, delirium, weight loss, swallowing problems, urinary tract
infections, mechanically altered diet, dependence for eating, bed mobility,
locomotion, number of medications, and age, while both CVA and tracheotomy
care were inversely predictive of pneumonia. The emergence of these
significant predictors suggested a different pathogenesis of pneumonia in the
elderly nursing home resident from the acute care patient or the outpatient.
Nursing home residents have chronic medical conditions that gradually lead to
“decompensation” in functional status, nutritional status, and pulmonary
clearance. Dysphagia and aspiration are common complications of their medical
conditions and may slowly worsen as their status deteriorates. Alternatively,
a sudden adverse event may dramatically increase the amount aspirated or the
ability to resist infection and lead to sudden decompensation. Clinical staff
must identify residents with dysphagia and aspiration and work to prevent
decline in functional status in all residents. They must be aware of the
dangers of adverse events that lead to sudden inactivity or illness and
increase the risk of aspiration pneumonia. Prevention of this disease whenever
possible will reduce costs, improve health outcomes, and improve our quality
of care.
Richard Morton, Jill Minford, Richard Ellis, Lorraine Pinnington :
Aspiration with Dysphagia: the Interaction Between Oropharyngeal and
Respiratory Impairments Dysphagia (3) 192-196 (2002)
Abstract:
Individuals with neurodisability and dysphagia often aspirate food
because of oropharyngeal impairments and poor control of respiration. This
study explored the interaction between these factors in 32 participants aged
3-33 years. Each person underwent a modified barium swallow study, during
which respiration was recorded and displayed simultaneously on the video
screen, in terms of inspiration, expiration, and velocity of airflow (TV data).
The duration of time that material remained in the pharynx before the swallow
(either because of pharyngeal delay or residue from the previous swallow) was
called the pharyngeal dwell time (PDT). The mean PDT of the 5 slowest swallows
for each participant was calculated for both liquids and thick purees. The
proportions of time spent in inspiration and expiration during the PDT in
seconds and a score representing the abnormality of inspiration, including its
frequency and velocity, were recorded. The volume of material in the pharynx
prior to these swallows was also estimated. Twelve participants aspirated
liquids and 3 of the 12 also aspirated thick purees. PDTs were longer among
aspirators (6.2 s) than nonaspirators (2.4 s) when consuming liquids. Also,
the percentage of the PDT spent in inspiration was greater among aspirators
than nonaspirators when taking liquids (31% vs. 11%) or thick purees (35% vs.
14%). During the PDT, aspirators showed more abnormal respiratory patterns for
liquids but not for purees. There were no differences in the volumes of liquid
or puree in the pharynx before the swallow between aspirators and
nonaspirators. A plot of the PDT against a combined respiratory impairment
score (i.e., percentage of the PDT spent in inspiration and respiratory
abnormality) predicted aspirators with a sensitivity of 83% and specificity of
95%. Aspiration results from oropharyngeal impairments with inadequate
respiratory integration. Further research is needed to investigate whether
intervention to improve respiratory control can reduce aspiration in people
with dysphagia.
Margareta Bülow, Rolf Olsson, Olle Ekberg : Supraglottic Swallow,
Effortful Swallow, and Chin Tuck Did Not Alter Hypopharyngeal Intrabolus
Pressure in Patients with Pharyngeal Dysfunction
Abstract:
Simultaneous videoradiography and solid-state manometry (videomanometry)
were performed in 8 patients (4 women, 4 men; age range = 46-81 years, mean
age = 70 years) with pharyngeal dysfunction in order to disclose any changes
in intrabolus pressure during swallowing maneuvers. Five of the patients had
severe pharyngeal dysfunction with frequent misdirected swallows. Three of the
patients had moderate pharyngeal dysfunction with delayed initiation of
pharyngeal swallow. Three different swallowing techniques were applied:
supraglottic swallow, effortful swallow, and chin tuck. Pharyngeal intrabolus
pressure was analyzed at the level of the inferior pharyngeal constrictor.
Supraglottic swallow, effortful swallow, and chin tuck did not alter peak
amplitude or duration of the intrabolus pressure.
C. Kley A1, J. Kaiser A1, R. Biniek : Dysphagie: Diagnostik auf der
Intensivstation Videoendoskopische und akustische Diagnostik
Abstract:
Rheinische
Kliniken Bonn Neurologische Abteilung 53108 Bonn, Germany E-Mail:
christoph.kley@gmx.de Zusammenfassung: Schluckstörungen sind in der Neurologie
ein sehr häufiges Problem. Unabhängig von der Grunderkrankung kann es aber auf
jeder Intensivstation im Zuge nachlassender Vigilanz des Patienten zu
Schluckstörungen kommen. Von den verschiedenen diagnostischen Möglichkeiten
ist die videoendoskopische Pharyngoskopie diejenige, die am ehesten auf einer
Intensivstation eingesetzt werden kann. Zusammen mit Schluckgeräuschen liefert
sie eine Reihe von Informationen über Art und Ausmaß der Schluckstörung. Es
ist eine komplikationsarme und einfach zu handhabende Untersuchungsmethode.
Jonathan E Aviv : The Bedside Swallowing Evaluation When Endoscopy Is
an Option: What Would You Choose?
Hierzu gibt es kein Abstract
Rosemary Martino : When to PEG?
Hierzu auch nicht!
Ruiying Ding, Charles R Larson, Jeri A Logemann, Alfred W Rademaker
: Surface Electromyographic and Electroglottographic Studies in Normal
Subjects Under Two Swallow Conditions: Normal and During the Mendelsohn
Manuever Dysphagia (1) 1-12 (2002)
Abstract:
Surface electromyography (EMG) has been used successfully in teaching
patients swallow maneuvers in clinical settings. The present study aims to
determine if surface EMG can reliably demonstrate differences in muscle
activity between the normal swallow and the Mendelsohn maneuver and whether
there is a close temporal relationship between submental muscles and laryngeal
elevation as demonstrated by electroglottography (EGG). Surface EMG was
measured from five muscle groups (superior and inferior orbicularis oris,
masseter, submental and infrahyoid) in 20 normal subjects under two swallowing
conditions: normal and during performance of the Mendelsohn maneuver. A
significant difference in EMG activity from the submental muscle group between
the normal swallow and the Mendelsohn maneuver indicates that EMG at this
location can be used reliably to differentiate between these two swallow
conditions. The onset of submental activity and laryngeal elevation occurred
within 10 ms of each other. The offset of submental activity and the return of
the larynx to its resting position occurred within 24 ms of each other.
Regarding the temporal relationship among the five muscle groups, the sequence
of the most frequent muscle initiation was orbicularis oris inferior,
orbicularis oris superior, masseter, submental muscle group, and infrahyoid
muscle group. The sequence of the most frequent muscle termination was
orbicularis oris superior, orbicularis oris inferior, masseter, submental
muscle group, and infrahyoid muscle group in both normal swallow and the
Mendelsohn maneuver.
Dysphagia journal: O.Ekberg et al: Social and psychological burden of
dysphagia: its impact on diagnosis and treatment . Dysphagia 17:139-146
(2002)
Abstract:
The social and psychological impact of dysphagia has not been
routinely reported in large studies. We sought to determine the effects of
dysphagia on broad measures of the quality of life of patients and to explore
the relationship between the psychological handicaps of the condition and the
frequency of diagnosis and treatment. A total of 360 patients selected on the
basis of known subjective dysphagia complaints, regardless of origin, in
nursing homes and clinics in Germany, France, Spain, and the United Kingdom
were interviewed using an established questionnaire. Qualitative interviews
with a total of 28 health professionals were conducted to improve
understanding of the patient data in the context of each country. Over 50% of
patients claimed that they were "eating less" with 44% reporting weight loss
during the preceding 12 months. Thirty-six percent of patients acknowledged
receiving a confirmed diagnosis of dysphagia; only 32% acknowledged receiving
professional treatment for it. Most people with dysphagia believe their
condition to be untreatable; only 39% of the sufferers believed that their
swallowing difficulties could be treated. Eighty-four percent of patients felt
that eating should be an enjoyable experience but only 45% actually found it
so. Moreover, 41% of patients stated that they experienced anxiety or panic
during mealtimes. Over one-third (36%) of patients reported that they avoided
eating with others because of their dysphagia. In a largely elderly population
that might accept dysphagia as an untreatable part of the aging process,
clinicians need to be aware of the adverse effects of dysphagia on self-esteem,
socialization, and enjoyment of life. Careful questioning should assess the
impact of the condition on each patient's life, and patients should be
educated on their choices for treatment in the context of any coexisting
illness. Awareness of the condition, diagnostic procedures, and treatment
options must be increased in society and among the medical profession.
Die Artikel von 1994 - 2004
Medizinische Forschungsartikel nach Themen geordnet: Allgemeine
Literatur:
Interessanter Artikel zum Thema Dysphagie-Screening:
DePippo KL,
Holas MA,
Reding MJ. :
The Burke dysphagia screening test: validation of its use in patients with
stroke.
Arch Phys Med Rehabil. 1995 Aug;76(8):788.
The objective of this study was to validate a dysphagia
screening test to identify patients in the rehabilitation phase post stroke at
risk for pneumonia, recurrent upper airway obstruction, and death. The setting
was an inpatient stroke rehabilitation unit. One hundred thirty-nine
consecutive patients met the following criteria: stroke confirmed by clinical
history and neurological exam with compatible computed tomography (CT) or
magnetic resonance imaging (MRI) scan; ages 20 to 90 years inclusive; and no
known history of significant oral or pharyngeal anomaly. The main outcome
measures were pneumonia, recurrent upper airway obstruction, and death. The
Burke Dysphagia Screening Test (BDST) identified 11 of 12 patients who
subsequently developed pneumonia, recurrent upper airway obstruction, or death
(Fisher's exact test: p = .03). The relative risk for the occurrence of any of
these complications was 7.65 times greater for those failing versus passing
the BDST. The BDST identified 9 of 9 patients who developed pneumonia (Fisher's
exact test: p = .01). We concluded that the BDST is of value in identifying
patients in the rehabilitation phase poststroke at risk for pneumonia,
recurrent upper airway obstruction, and death.
Bartolome G, Buchholz DW, Feussner H, Hannig Ch, Neumann S,
Prosiegel M, Schröter-Morasch H, Wuttge-Hannig A. Schluckstörungen, Diagnostik
und Rehabilitation. 2. Auflage. München: Urban & Fisher; 1999.
Davis P. Wieder
aufstehen. Berlin: Springer Verlag; 1994
Rezension amazon.de: In ihrem
neuen Buch beschäftigt sich die Autorin von "Hemiplegie" (STEPS TO FOLLOW) mit
der Frührehabilitation von Patienten, die ein Hirntrauma oder eine ähnliche
schwere Hirnschädigung erlitten haben. Sie stellt ein umfangreiches Spektrum
von Behandlungsmöglichkeiten vor, angefangen von der Intensivbehandlung bis
hin zum Neuerlernen des Gehens. Illustriert und ergänzt werden ihre
detailgenauen Anleitungen durch mehr als 600 Fotos von Patienten und
Therapeuten in alltäglichen Behandlungssituationen. Der Leser erfährt alles
über den Umgang mit Wahrnehmungsstörungen bei Patienten, über das Lagern,
Bewegen und Stehen (auch mit dem noch bewusstlosen Patienten), die Schulung von
Gleichgewichtsinn und motorischer Kontrolle und die Vermeidung von
Kontrakturen.
Dikeman, K.J., M. Kazandjian (1995). Communication and
swallowing management of tracheostomized and ventilator-dependent adults. San
Diego: Singular Publishing Group.
Donner, M.W., B. Jones (1991). Aging and neurological disease. In: Jones,
B., M. Donner. Normal and abnormal swallowing. Imaging in diagnosis and
therapy. New York: Springer Verlag
Rezension bei amazon: From Book
News, Inc. A practical guide to the role of imaging in the diagnosis and
treatment of the patient with dysphagia, defining the role of the newer
modalities such as ultrasound, computed tomography, and magnetic resonance
imaging in perspective, indicating what each modality has to offer. The text
concentrates on pharyngeal disease, but also emphasizes the interrelationships
between pharynx and esophagus which result in the safe, efficient transport of
ingested food and liquid from mouth to stomach. Includes a glossary of words
and phrases commonly used in discussing pharyngeal structure or function.
Annotation copyright Book News, Inc. Portland, Or.
Groher, M.E. (1992). Dysphagia. Diagnosis and management. Boston:
Butterworth.
Kahrilas P, Lin S, Chen J, Logemann J.
Oropharyngeal accomodation to swallow volume. Gastroenterology
1996;111:297-306
Kuhlemeier, K.V. (1994). Epidemiology and dysphagia.
Dysphagia, 9:209-17
Langley, J. (1994). Working with swallowing disorders.
Bicester, Oxon: Winslow Press
Langmore S. Issues in the management of
dysphagia. Folia Phoniatrica et logopaedica 1999;51:220-30
Logemann J.
Evaluation and treatment of swallowing disorders. Austin: Pro-Ed;1983.
Logemann, J.A. (1995). Dysphagia: evaluation and therapy. Folia
Phoniatrica et Logopaedica, 47:140-164
Logemann J. Evaluation and treatment
of swallowing disorders. 2nd ed. Austin: Pro-Ed;1999
Logemann J. Manual
for the videofluorographic evaluation of swallowing disorders. Austin:
Pro-Ed; 1995
Logemann J. Behavioral management for oropharyngeal dysphagia.
Folia Phoniatrica et logopaedica 1999; 51: 199-212
Logemann, J.A. (1997).
Therapy for oropharyngeal swallowing disorders. In: Perlman, A.L., K.
Schulz-Delrieu (1997). Deglutition and its disorders. Anatomy, physiology,
clinical diagnosis and management. San Diego: Singular Publishing.
McKaig, T.N.,
J. Thibodeau (1998). Bedside assessment of swallowing safety (BASS).
Abstract:
Boston: Butterworth-Heinemann Bedside Assessment of Swallowing Safety (BASS)
is the first software program designed by a clinician to provide a bedside
evaluation protocol for accurate diagnosis of the dysphagic patient. This
innovative test protocol and user's manual provide an efficient and
easy-to-use program to assist the clinician in documentation, consistent
reporting and patient diagnosis. FEATURES Leads clinicians step-by-step
through the evaluation and report-writing process Includes information on the
medical history review, physical examination, lab evaluation, dietary levels,
and behavioral therapy Produces effective patient reports in terms easily
understood by third - party billing agencies CONTENTS
Overview,Introduction,Installing the BASS, Starting the BASS,The BASS Menu
Bar, Clinical Observations: How to Test Voice Quality, Muscles of
Mastication,Strap Muscles,Jaw Muscles,Primitive or Pathological Reflexes:
Voice: Vegetative Swallow,Labial Tone Labial Seal,Labial Range of
Motion,Tongue How to Observe the Tongue at Rest, How to Observe the Mucous
Lining, How the Observe the Velum or Soft Palate, How to Observe a Reflexive
Cough, Overview of Test Swallow, Short-Term Goals, Oral Motor Exercises,
Labial Seal Exercises, Oral Motor Exercises for Control of Bolus, Thermal
Stimulation to Elicit Swallow Reflex, Pharyngeal Motor Control Exercises,
Laryngeal Adduction Exercises, The Mendelsohn Maneuver, The Supraglottic
Swallow, Patient/Staff Education, Patient/Family Education, Dietary
Modification - Nutrition, Dietary Modification - Hydration, Therapeutic
Positioning of the Patient, References and Suggested Readings Resources,
Glossary hier gibt es eine Internetadresse:
www.telstarcenter.com/mckaignet/research.htm
Miller, R.M., M. Groher (1993). Speech-language pathology and dysphagia:
a brief historic perspective. Dysphagia, 8: 180-184
Miller, R.M., S.
Lagmore (1994). Treatment efficacy for adults with oropharyngeal dysphagia.
Archives of Physical Medicine and Rehabilitation, 75:1256-1262
Oetter P, Richter E, Frick S. M.O.R.E., integrating the mouth with
sensory and postural functions. 2nd ed. Minnesota: PDP-press; 1995
Perlman
A, Schulze-Delrieu K. Deglutition and its Disorders. Anatomy, physiology,
clinical diagnosis and management. San Diego:Singular;1997
amazon-Rezension Provides current information on normal and disordered
swallowing, for professionals and students in speech-language pathology,
gastroenterology, radiology, otolaryngology, pulmonology, and neurology.
Coverage includes functional controls of deglutition; clinical assessment of
dysphagia radiographic contrast, endoscopic, and electromyographic examination;
diseases affecting swallowing; the pediatric patient; and medical and surgical
treatment. Includes b&w photos, multiple-choice questions and answers, and a
glossary. -- Copyright © 1999 Book News, Inc., Portland, OR All rights
reserved
Stringer S: Managing dysphagia in palliative care. Professional
Nurse 1999;14(7):489-492
Sullivan, P.A., A. Guilford (1999). Swallowing
intervention in oncology. San Diego: Singular Publishing.
amazon-Rezension From Book News, Inc. Provides medical and health care
professionals with clinical information on the causes and treatment of
dysphagia in persons with head and neck cancer. Details practical strategies
for management and rehabilitation of this patient population, focusing on
team-based collaboration, with contributions from multi-specialty oncology
experts. Contains chapters on oncology principles, chemotherapy and radiation
therapy, malignancies and management, and legal and ethical issues. Stories of
survivors are told through b&w photos and essays. Book News, Inc.®, Portland,
OR
White, P.F. (1997). Pocket Reference of diagnosis and management for the
speech-pathologist. Boston: Butterworth.
amazon-Rezension Book Info
Methodist Hospital Central, Memphis, TN. A pocket-sized quick reference for
speech-language pathologists, providing tables and lists of essential
information, as well as updates on commonly prescribed drugs and their effects
on speech and language. Covers a wide spectrum of speech pathology disorders
and conditions. Previous edition: c1997. Softcover.
Hier geht es zurück zur Übersicht.
ALS / IBM
Laryngeal dysfunction in Amyotrophic
Lateral Sclerosis: a review and case report
Christopher R Watts
1
and Martine Vanryckeghem
2
1Department of Speech Pathology & Audiology, University of
South Alabama, Mobile, AL, USA
2Department of Communicative Disorders, University of Central
Florida, Orlando, FL, USA
Received September 5, 2001; Accepted November 13, 2001.
Laryngeal dysfunction can be a salient feature in the clinical
symptomatology of speakers diagnosed with Amyotrophic Lateral Sclerosis (ALS).
In addition to dysphonia, swallowing function is also disrupted. This paper
reviews what is known about laryngeal dysfunction resulting from ALS.
Results
Presented is a case report of a female, diagnosed with ALS, whose initial
symptoms were caused by laryngeal bulbar involvement that was characterized by
dysphonia and dysphagia.
Conclusions
In bulbar forms of ALS, voice and/or swallowing difficulties are often the
initial signs of disease. Careful examination of the muscles innervated by
bulbar nerves, and tracking the rate of progressive deficit in the affected
muscles, will help to solidify an accurate diagnosis. With therapy, the
ability to swallow safely may still be maintained even when voice and
articulation abilities are such that oral communication is inefficient.
PDF - Freeversion
http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=60006&blobtype=pdf
Brain, Vol. 123, No. 1,
125-140, January 2000
© 2000
Oxford University Press
Pathophysiological mechanisms of oropharyngeal
dysphagia in amyotrophic lateral sclerosis
Cumhur Ertekin1,2
,
Ibrahim Aydogdu1,2, Nur Yüceyar2,
Nefati Kiylioglu2, Sultan Tarlaci2
and Burhanettin Uludag1,2
1
Departments of Clinical Neurophysiology and 2 Neurology, Medical
School Hospital, Ege University Bornova, Izmir, Turkey
Correspondence to: Professor
Cumhur Ertekin, Nilhan Apt. 1357 Sok. No. 1 D-10, Alsancak, Izmir, Turkey
E-mail:
erteker@unimedya.net.tr
We investigated the pathophysiological
mechanisms of dysphagia in amyotrophic lateral sclerosis.
Forty-three patients with sporadic amyotrophic lateral sclerosis
were examined by clinical and electrophysiological methods that
objectively measured the oropharyngeal phase of voluntarily
initiated swallowing, and these results were compared with those
obtained from 50 age-matched control subjects. Laryngeal movements
were detected by a piezoelectric sensor and EMG of submental
muscles, and needle EMG of the cricopharyngeal muscle of the upper
oesophageal sphincter of both the amyotrophic lateral sclerosis and
control groups was recorded during swallowing. Amyotrophic lateral
sclerosis patients with dysphagia displayed the following abnormal
findings. (i) Submental muscle activity of the laryngeal elevators,
which produce reflex upward deflection of the larynx during wet
swallowing, was significantly prolonged whereas the laryngeal
relocation time of the swallowing reflex remained within normal
limits. (ii) The cricopharyngeal sphincter muscle EMG demonstrated
severe abnormalities during voluntarily initiated swallows. The
opening of the sphincter was delayed and/or the closure occurred
prematurely, the total duration of opening was shortened and, at
times, unexpected motor unit bursts appeared during this period.
(iii) During voluntarily initiated swallows there was significant
lack of co-ordination between the laryngeal elevator muscles and
the cricopharyngeal sphincter muscle. These results point to two
pathophysiological mechanisms that operate to cause dysphagia in
amyotrophic lateral sclerosis patients. (i) The triggering of the
swallowing reflex for the voluntarily initiated swallow is delayed
and eventually abolished, whereas the spontaneous reflexive
swallows are preserved until the preterminal stage of amyotrophic
lateral sclerosis. (ii) The cricopharyngeal sphincter muscle of the
upper oesophageal sphincter becomes hyper-reflexic and hypertonic.
As a result, the laryngeal protective system and the bolus
transport system of deglutition lose their co-ordination during
voluntarily initiated swallowing. We conclude that these
pathophysiological changes are related mainly to the progressive
degeneration of the excitatory and inhibitory corticobulbar
pyramidal fibres.
PDF-Freeversion:
http://brain.oxfordjournals.org/cgi/reprint/123/1/125
Amin MR,
Harris D,
Cassel SG,
Grimes E,
Heiman-Patterson T.: Sensory testing in the
assessment of laryngeal sensation in patients with amyotrophic lateral
sclerosis.
Ann Otol Rhinol Laryngol.
2006 Jul;115(7):528-34.
OBJECTIVES: Amyotrophic lateral sclerosis (ALS) is a
progressive motor neuron disease of unknown cause. Mortality in the population
is frequently due to aspiration pneumonia. Although typically considered to be
a disorder limited to motor neuron involvement, some investigators have
indicated that decreased sensory function in ALS patients additionally
contributes to the disease process. The objective of this study was to
evaluate laryngopharyngeal sensation in the ALS population in order to
quantify the range of sensory deficits and correlate any abnormalities with
demographic data to determine which patients are at risk of having sensory
deficits. METHODS: We examined the sensation of the larynx in 22 patients with
ALS to determine whether a sensory deficit was present. After completion of a
dysphagia questionnaire and medical history, patients underwent flexible
endoscopic evaluation of swallowing with sensory testing (FEESST) to evaluate
sensory function. Threshold values were determined and recorded for initiation
of the adductor reflex. RESULTS: The results of the sensory and swallowing
function assessments performed on 22 patients demonstrate abnormal sensation
in 54.5% of the tested population. Asymmetric findings were noted in 75% of
these patients. There was no correlation noted between the presence of sensory
deficits and the severity or duration of the disease. CONCLUSIONS: Progressive
dysphagia in the ALS population has typically been attributed to muscle
weakness. This study points to the presence of sensory deficits in the larynx,
which can further affect proper swallowing function.
Houser, S.M., L. Calabrese, M. Strone (1998). Dysphagia in patients with
inclusion body myositis. The Laryngoscope, 108:1001-1005
Abstract:
OBJECTIVES: Inclusion body myositis (IBM) is an inflammatory
myopathy with a 40% reported incidence of dysphagia. A protracted course,
refractory to medical therapy, frequently leads to consultation with an
otolaryngologist for dysphagia management. We studied the incidence, symptoms,
and mechanisms of dysphagia in patients with IBM. STUDY DESIGN: Retrospective
study of medical records and self-reported follow-up survey; dysphagia is
defined as difficulty in swallowing. MATERIALS: Twenty-two patients with
biopsy-proven IBM. RESULTS: The rate of dysphagia was more than 80% (16 of
19), twice as high as previously reported. Progressive dysphagia was
associated with a significantly worse functional class. Relevant management
guidelines are established, including the timing for appropriate surgical
intervention. CONCLUSION: Progressive dysphagia may signify more aggressive
IBM or an episodic worsening in status. Recognition of the disease
manifestations will afford proper patient management. Informed
otolaryngologists can have a favorable impact on the dysphagia associated with
IBM.
Mazzini, L., T. Corra, M. Zaccala, G. Mora, M. del Piano, M. Galante (1995)
Percutaneous endoscopic gastrostomy and enteral nutrition in amyotrophic
lateral sclerosis. Journal of Neurology, 242:695-698
Abstract:
Bulbar involvement in amyotrophic lateral sclerosis (ALS) is
often related to a worse prognosis on account of the higher risk of pulmonary
aspiration and undernutrition due to dysphagia. The aim of our study was to
assess the effects of enteral feeding by percutaneous endoscopic gastrostomy
(PEG) in a long-term follow-up of ALS patients. We report the results of PEG
in 31 ALS patients with bulbar involvement. The patients were observed at
3-monthly intervals over a period of 2 years after PEG. All the data were
compared with those obtained from a control group of 35 ALS patients who
refused PEG. Mortality did not differ significantly between the two groups of
patients during the first 6 months of observation, whereas after this period
it was lower in the PEG group. In the patients who had had PEG, the body mass
index showed a mild but statistically significant improvement after tube
insertion while in the control group it decreased significantly. The findings
of this study demonstrate that PEG can improve survival in elderly and young
ALS patients with bulbar involvement; it enhances their quality of life and
helps their integration in their social and family surroundings. We think that
PEG should be included symptomatic treatment of all ALS patients with bulbar
involvement from the onset of symptoms.
Strand, E.A., R. Miller, K. Yorkston, A. Hillel (1996). Management of
oral-pharyngeal dysphagia symptoms in amyotrophic lateral sclerosis.
Dysphagia, 11:129-139
Abstract:
Oral and pharyngeal dysphagia is a common symptom in patients
with amyotrophic lateral sclerosis (ALS) and is the result of a progressive
loss of function in bulbar and respiratory muscles. Clinicians involved in the
management of ALS patients should be familiar with the common clinical
findings and the usual patterns of temporal progression. The prevention of
secondary complications, such as nutritional deficiency and dehydration that
compound the deteriorating effects of the disease, requires careful monitoring.
Willig, T.N., J. Paulus, J. Lacau Saint Guily, C. Beon, J. navarro (1994).
Swallowing problems in neuromuscular disorders. Archives of Physical
Medicine and Rehabilitation, 75:1175-1181
Abstract:
Feeding problems in patients with neuromuscular diseases are
frequently underestimated and poorly analyzed. To gain a better understanding
of the most common complaints, we surveyed 451 patients and received 409
responses representing seven disorders. Difficulties in the pre-oral phase of
swallowing were encountered primarily in Duchenne muscular dystrophy (DMD),
limb-girdle muscular dystrophy (LGMD), facio-scapulo-humoral muscular
dystrophy (FSHMD), and spinal muscular atrophy (SMA). A limitation in the
ability to open the mouth was also noted in SMA. Some features are
characteristic of certain diseases such as macroglossia in DMD and dryness of
the mouth in dermatomyositis and polymyositis (DMPM) and myasthenia gravis
(MG). Posterior swallowing time is especially affected in MG, dermatomyositis
and polymyositis, LGMD, and SMA. Overall prevalence of feeding disability in
five disorders (SMA, myotonic dystrophy [MD], DMPM, FSHMD, MG) was 34.9%. A
better understanding of the swallowing problems associated with these
disorders may help in choosing treatment possibilities, technical aids,
adaptation of the consistency of foods, swallowing rehabilitation, and
nutritional support by the non-oral route.
Hier geht es zurück zur Übersicht.
4. Dysphagie bei multipler Sklerose
Dysphagie bei Multipler Sklerose
Terre-Boliart R, Orient-Lopez F, Guevara-Espinosa D, Ramon-Rona S,
Bernabeu-Guitart M, Clave-Civit P.:
Oropharyngeal dysphagia in patients with multiple sclerosis.
Revista de Neurol. 2004 Oct 16-31;39(8):707-10.
Abstract:
AIMS. The aim of this study is to evaluate the prevalence of the clinical and
videofluoroscopic (VDF) symptoms of oropharyngeal dysphagia in patients with
multiple sclerosis, and to describe its therapeutic management. PATIENTS AND
METHODS. We studied 23 patients suffering from multiple sclerosis to evaluate
the characteristics of the disease, the VDF exploration of swallowing and
therapeutic strategies. The VDF exploration enables us to define the VDF
symptoms that assess the safety and efficiency of swallowing for the oral and
pharyngeal phases. The therapeutic strategies include: changes in the
characteristics of the diet, changes of posture and active manoeuvres.
RESULTS. The patients studied presented a mean EDSS score 7.4 (4-9). There
were alterations in swallowing efficiency and/or safety in more than 80% of
the patients. In 52% there was some change in the swallowing safety. 40% of
them were silent aspirators. All these patients were fed orally without any
complications, in 78% the volume of the bolus has been modified and changes
have taken place in the consistency (thickening for liquids); in 43%,
moreover, postural strategies were employed and active manoeuvres
(supraglottic swallow) were introduced in 13% in order to improve swallowing
safety. CONCLUSIONS. There is a high prevalence of clinical and VDF symptoms
of oropharyngeal dysphagia in patients with advanced multiple sclerosis. VDF
enables us to diagnose the pathophysiological mechanism of aspiration and the
existence of silent aspirators, and helps us to introduce specific therapeutic
interventions for each patient, thereby achieving safe and efficient
swallowing, while prolonging oral feeding.
Prosiegel
M, Schelling A, Wagner-Sonntag E.: Dysphagia and multiple sclerosis.
Int MS J. 2004 Apr;11(1):
22-31.
Abstract:
Over 30% of
persons with multiple sclerosis (pwMS) suffer from swallowing symptoms, a
higher rate than previously assumed. Neurogenic dysphagia (ND) may cause many
different kinds of oropharyngeal sensorimotor dysfunctions in pwMS, and is
associated with both the amount of disability and brainstem signs. About 15%
of pwMS with mild disability may also suffer from ND. Diagnostic tools
comprise history taking, bedside screening examination (50 ml water test
combined with assessment of pharyngeal sensation or with pulse oximetry) and
sometimes a videofluoroscopic swallowing study (VFSS) and fibreoptic
endoscopic evaluation of swallowing (FEES). VFSS and FEES are complementary
methods and both have advantages and disadvantages. Interventions for ND in
pwMS are mainly based on functional swallowing therapy, including methods of
restitution, compensation and adaptation. The aim of intervention is to
prevent aspiration and aspiration pneumonia. Outcome assessment should focus
on clinically relevant parameters, such as activity limitation, participation
restriction and health-related quality of life.
Fiske J,
Griffiths J, Thompson S.:
Multiple sclerosis and
oral care. Dent Update. 2002
Jul-Aug;29(6):273-83.
Abstract:
Multiple sclerosis
is a complex neurological condition affecting sensory and motor nerve
transmission. Its progression and symptoms are unpredictable and vary from
person to person as well as over time. Common early symptoms include visual
disturbances, facial pain or trigeminal neuralgia and paraesthesia or numbness
of feet, legs, hands and arms. These, plus symptoms of spasticity, spasms,
tremor, fatigue, depression and progressive disability, impact on the
individual's ability to maintain oral health, cope with dental treatment and
access dental services. Also, many of the medications used in the symptomatic
management of the condition have the potential to cause dry mouth and
associated oral disease. There is no cure for multiple sclerosis, and
treatment focuses on prevention of disability and maintenance of quality of
life. Increasingly a multi-disciplinary team approach is used where the
individual, if appropriate his/her carer, and the specialist nurse are key
figures. The dental team plays an essential role in ensuring that oral health
impacts positively on general health.
De Pauw A,
Dejaeger E, D'hooghe B, Carton H.: Dysphagia in
multiple sclerosis.
Clin Neurol
Neurosurg. 2002 Sep;104(4):345-51
Abstract:
OBJECTIVES: (1) To determine the prevalence of swallowing problems in MS
patients and its relation to the overall disability. (2) To define the most
frequent symptoms suggestive of dysphagia. (3) To describe the abnormalities
on manofluoroscopy (MFS). METHODS: Three hundred and eight consecutive MS
patients were asked whether they ever had swallowing problems. If so the
questionnaire of the Johns Hopkins Swallowing Centre was applied to qualify
the dysphagia. A MFS was performed in 30 patients with dysphagia covering the
entire spectrum of MS. Overall disability was assessed using the Expanded
Disability Status Scale (EDSS). RESULTS: Seventy-three of our 309 patients had
permanent dysphagia (24%). Another 5% had a history of transitory swallowing
problems only. Permanent dysphagia started to be a problem in mildly impaired
patients (EDSS 2-3). Prevalence increased together with rising disability to
reach 65% in the most severely disabled subjects (EDSS 8-9). Two alarming
symptoms of patients with swallowing problems, coughing or choking during the
meal and a history of pneumonia were present in 59%, respectively, 12% of
these patients. MFS showed deficiency of the oral phase in all patients, while
only the patients with an EDSS higher than 7.5 showed abnormalities of the
pharyngeal phase. CONCLUSIONS: Permanent dysphagia may already develop in
mildly impaired MS patients but becomes a rather frequent finding in MS
patients with moderate or severe disability. MFS is a sensitive and useful
ancillary examination. Important qualitative changes of the pharyngeal phase
on MFS are seen in patients with an EDSS higher than 7.5.
Wiesner W, Wetzel SG, Kappos L, Hoshi MM, Witte U,
Radue EW, Steinbrich W. : Swallowing abnormalities in multiple
sclerosis: correlation between videofluoroscopy and subjective symptoms.
Eur Radiol. 2002 Apr;12(4):789-92. Epub 2001 Sep 05.
Abstract:
The purpose of this study was to evaluate if subjective symptoms indicating an
impaired deglutition correlate with videofluoroscopic findings in patients
with multiple sclerosis (MS). Videofluoroscopic examinations of 18 MS patients
were analyzed by a radiologist and a logopedist and compared with the symptoms
of these patients. Four patients complained about permanent dysphagia. Six
patients reported mild and intermittent difficulties in swallowing, but were
asymptomatic at the time of videofluoroscopy. Eight patients had no symptoms
regarding their deglutition. All patients ( n=4) who complained of permanent
dysphagia showed aspiration. All patients ( n=6) with mild and intermittent
difficulties in swallowing showed undercoating of the epiglottis and/or
laryngeal penetration. Of those 8 patients without any swallowing symptoms,
only 2 had a normal videofluoroscopy. Swallowing abnormalities seem to be much
more frequent in patients with MS than generally believed and they may easily
be missed clinically as long as the patients do not aspirate.
Calcagno P, Ruoppolo G, Grasso MG, De Vincentiis M,
Paolucci S.: Dysphagia in multiple sclerosis - prevalence and
prognostic factors. Acta Neurol Scand. 2002 Jan;105(1):40-3.
Abstract:
The aim of the study was to analyse swallowing function and to identify
reliable prognostic factors associated with dysphagia in a consecutive series
of patients with multiple sclerosis (MS). Swallowing examination was performed
by means of indirect and direct methods (fiberendoscopic evaluation) in 143
consecutive patients with primary and secondary progressive MS. Dysphagia was
found in 49 patients (34.3%). A close relationship with dysphagia was found in
the patients with severe brainstem impairment (OR=3.24; 95% CI 1.44-7.31) as
compared to the patients without. There was also a significant correlation
with pronounced severity of illness (OR=2.99; CI 1.36-6.59). Compensatory
strategies were sufficient to resolve the dysphagia in 46 cases (93.8%). The
potential risk of aspiration and malnutrition and the high efficacy of
swallowing rehabilitation suggests that all MS patients should have a careful
evaluation of deglutition functionality, especially those with brainstem
impairment and a high grade of disability level.
Abraham SS, Yun PT: Laryngopharyngeal
dysmotility in multiple sclerosis. Dysphagia. 2002 Winter;17(1):69-74.
Abstract:
This study investigated the swallowing physiology of 13 patients [age 27-69
years (mean = 45 years)] with multiple sclerosis (MS) who had Kurtzke Extended
Disability Status Scale (EDSS) scores ranging from 2 to 9 (mean = 6) and who
complained of difficulty swallowing. Videofluoroscopic recordings of the
patients' calibrated liquid and paste bolus swallows were analyzed and
compared with published normative data. Results showed that swallowing
physiology was disordered in the 13 MS patients with severity level ranging
from mild to severe. Eleven patients had primary pharyngeal dysphagia. 1
patient had primary laryngeal dysphagia, and 1 patient had primary oral
dysphagia. Laryngeal dysmotility, the predominant anterior pharyngeal segment
dysfunction, was evidenced in all 13 patients with MS. They displayed
significantly longer-than-normal pharyngeal delay times, shorter-than-normal
time intervals from onset of laryngeal excursion to return to rest. and
longer-than-normal time intervals between airway closure at the arytenoid to
epiglottic base and upper esophageal sphincter opening. Pharyngeal constrictor
dysmotility, the predominant posterior pharyngeal segment dysfunction, was
observed in 11 of the 13 MS patients. A significant relationship was found
between the severity of the MS patients' functional swallowing impairment and
posterior pharyngeal segment dysfunction. Material penetrated the supraglottic
airway of 9 patients with 1 patient aspirating. A significant relationship was
observed between supraglottic penetration and brainstem dysfunction. No
significant relationship was found between severity of dysphagia and
neurological disability as measured by EDSS scores or neurological impairment
as measured by Functional System (FS) scores. Disturbed neuromotor sequencing
of laryngeal events and a progression in neuromotor weakening of the
pharyngeal constrictors were suggested from the findings.
Miani C, Bergamin AM, Passon P, Rugiu MG, Staffieri
A: Videofluoroscopic study of deglutition in patients with multiple
sclerosis. Acta Otorhinolaryngol Ital. 2000 Oct;20(5):343-6.
Abstract:
Multiple sclerosis is a neurological disease that
affects the I/II motor neurons of the CNS and its symptoms include
oropharyngeal dysphagia. The onset and course of this dysphagia significantly
conditions the progression of the disease. The present study evaluates the
incidence on deglutition and type of alterations in a sampling of 10 multiple
sclerosis patients of which 4 showed clinical signs of dysphagia. The results,
obtained by combining quantitative (clinical severity) and qualitative
(functional alterations) parameters showed that 9 of the 10 patients (90%)
presented radiological abnormalities in the progression of the bolus. The
conclusion drawn is that the high prevalence of dysphagia in multiple
sclerosis, even if not always manifest clinically, justifies drawing up a
standard protocol for radiological evaluation and clinical follow-up in order
to screen those patients at greater risk of pulmonary complications and delay
them as long as possible.
Thomas FJ, Wiles CM.: Dysphagia and
nutritional status in multiple sclerosis. J Neurol. 1999
Aug;246(8):677-82.
Abstract:
In this observational study of patients with multiple sclerosis (MS) admitted
to a regional neurology centre we assessed the frequency of dysphagia
(objectively defined), dysphagia related symptoms, bulbar signs and
nutritional status. We studied 79 consecutive admissions with MS (24 at
diagnostic admission and 55 more advanced cases admitted for treatment and/or
rehabilitation): normative swallowing data were from 181 healthy controls.
Swallowing symptoms and signs were semi-quantitatively measured and compared
to healthy controls. Dysphagia was defined by a quantitative water test.
Disability was determined by Kurtzke's Expanded Disability Status Scale and
Barthel's index. Nutritional status was assessed by body mass index, estimated
percentage body fat from skin fold thickness measurements at four sites, a
global evaluation of nutrition, the presence of pressure sores and the
pressure sore risk using the Waterlow score. Patients with MS were more likely
to complain of abnormal swallowing, of coughing when eating, and of food
'going down the wrong way' than healthy controls (P < 0.005). These
significantly associated symptoms had high specificity but relatively low
sensitivity. 43% of patients had abnormal swallowing, almost half of whom did
not complain of it: abnormal swallowing was associated with several factors
including abnormal brainstem/cerebellar function, disability, vital capacity,
and depression score. Those with abnormal swallowing had higher Waterlow
scores (P < 0.001), but, overall, abnormal swallowing was not associated with
a difference in nutritional indices or incidence of pressure sores. In
summary, abnormal swallowing is common in MS although often not complained of.
It is associated with disordered brainstem/cerebellar function, overall
disability, depressed mood and low vital capacity. It was not associated with
major nutritional failure or pressure sores in this study.
Merson RM, Rolnick MI.: Speech-language
pathology and dysphagia in multiple sclerosis. Phys Med Rehabil Clin N Am.
1998 Aug;9(3):631-41.
Abstract:
Dysarthria occurs in approximately 40% of all patients with MS. When speech
and voice disturbances do occur, they usually present as a spastic-ataxic
dysarthria with disorders of voice intensity, voice quality, articulation, and
intonation. While language disturbances such as aphasia, auditory agnosia,
anomia, dysgraphia, and dyslexia are very rare in MS, cognitive deficits and
swallowing disorders are common. Treating dysarthria, dysphagia, and cognitive
deficits in MS patients is effective for reestablishing functional daily
activities. The types, severity, and rates of deterioration in MS are highly
variable; complete restoration to normal functioning is therefore not always
expected. For these reasons, careful documentation of clinical-treatment
outcomes and the factors influencing these outcomes should be regularly
collected and reported.
Hartelius L, Svensson P.: Speech and
swallowing symptoms associated with Parkinson's disease and multiple
sclerosis: a survey. Folia Phoniatr Logop. 1994;46(1):9-17.
Abstract:
A survey of approximately 460 patients with Parkinson's
disease (PD) or multiple sclerosis (MS) shows that speech and swallowing
difficulties are very frequent within these groups. Seventy percent of the PD
patients and 44% of the MS patients had experienced impairment of speech and
voice after the onset of their disease. Forty-one percent of the PD patients
and 33% of the MS patients indicated impairment of chewing and swallowing
abilities. The speech disorder was regarded as one of their greatest problems
by 29% of the PD patients and by 16% of the MS patients. Only a small number
of patients, 3% of the PD and 2% of the MS group, had received any speech
therapy.
Garfinkle TJ, Kimmelman CP.: Neurologic
disorders: amyotrophic lateral sclerosis, myasthenia gravis, multiple
sclerosis, and poliomyelitis. Am J Otolaryngol. 1982 May-Jun;3(3):204-12
Abstract:
The patient who has multiple cranial neuropathies may pose a diagnostic
dilemma. The neurologic disorders of amyotrophic lateral sclerosis, multiple
sclerosis, myasthenia gravis, and poliomyelitis often cause bulbar
dysfunctions such as diplopia, facial weakness, slurred or hypernasal speech,
dysphagia, and hoarseness. In general, treatment is supportive and is directed
toward restoring or aiding lost function (i.e., tracheostomy, esophagostomy,
and cricopharyngeal myotomy). The relative infrequency of these disorders can
lead to delays in diagnosis and rehabilitative therapy.
Hier geht es zurück zur Übersicht.
Dysphagie bei älteren Menschen
Dysphagie bei älteren Menschen
Ein sehr interessanter Artikel zum Thema von 2003:
Jo Shapiro, M.D., and Lorraine Downey, M.S., CCC-SLP
: The Evaluation and Management of Swallowing Disorders in the Elderly;
Geriatric Times, 2003
Link:
www.geriatrictimes.com/g031217.html
Anthony James, Kapil Kapur, A. Barney Hawthorne: Long-term
outcome of percutaneous endoscopic gastrostomy feeding in patients with
dysphagic stroke. Age and Ageing, Nov. 1998
Abstract:
Objective: investigation of length of survival, complications,
level of dependence and recovery of swallow in patients who received
percutaneous endoscopic gastrostomy (PEG) feeding for dysphagia due to stroke.
Design: a retrospective case note analysis of patients treated between 1991
and 1995 and telephone survey of modified Barthel index in October 1996.
Setting: Cardiff Royal Infirmary and the University Hospital of Wales in
Cardiff. Subjects: 126 patients who had PEG inserted after dysphagic stroke.
Main outcome measures: complications of PEG, length of survival, duration of
PEG feeding, recovery of swallow and modified Barthel index score. Results:
median length of follow-up was 31 months (range 4-71). Median duration of PEG
use was 127 days (range 1-1372). For patients with PEG inserted within 2 weeks
the median duration was 52 days (range 2-1478). At follow up 36 (29%) had had
PEG removed, 72 (57%) had died with PEG in use, 10 (8%) still had PEG and were
nil by mouth and five (4%) had PEG in use with swallow recovered. The median
survival was 305 days. Thirty-five (28%) patients died in hospital. Aspiration
pneumonia was the commonest complication. Thirty-three patients were alive in
October 1996. The modified Barthel index for nursing home patients was 4 (range
O- 13) and for patients at home 11 (range 2-20). Conclusion: PEG feeding is
safe and well tolerated in patients with dysphagic stroke. Early PEG placement
(within 2 weeks) is worthwhile with many going on to have long-term feeding.
Although overall mortality is high, some patients have a long-term survival
and a few attain a reasonable level of function in daily living activities.
Late recovery of swallow occurs and patients should have follow-up swallowing
assessment.
Schindler JS, Kelly JH. Swallowing disorders in the elderly.
Laryngoscope. 2002 Apr;112(4):589-602.
Abstract:
Changes that occur as a natural part
of senescence in the complex action of deglutition predispose us to dysphagia
and aspiration. As the "baby-boomers" begin to age, the onset of swallowing
difficulties will begin to manifest in a greater number of our population.
Recent advances in the evaluation of normal and abnormal swallowing make
possible more precise anatomical and physiological diagnoses. Coupled with an
understanding of swallowing physiology, such detailed evaluation allows
greater opportunity to safely manage dysphagia with directed therapy and
appropriate surgical intervention. The current study is a discussion of the
changes that occur in deglutition with normal aging, contemporary evaluation
of swallowing function, and some of the common causes of dysphagia in elderly
patients.
Miyazaki Y, Arakawa M, Kizu J. Introduction of simple swallowing ability
test for prevention of aspiration pneumonia in the elderly and investigation
of factors of swallowing disorders. Yakugaku Zasshi. 2002
Jan;122(1):97-105.
Abstract:
Aspiration pneumonia is a major cause of death in the
elderly. In this study, a water swallowing test was introduced as a method of
evaluating the swallowing ability of patients, and a swallowing ability
evaluation team investigated an appropriate procedure and evaluation method
for the situation of our hospital. We also investigated the relationship
between the swallowing ability of patients examined by the water swallowing
test and underlying diseases, complications, and medicated drugs. In the water
swallowing test, the water-drinking method was fixed, and evaluation was made
based on the time required for drinking, profile, and episodes, by which
patients suspected of swallowing disorder were detected, confirming the
usefulness of this method. The frequency of developing swallowing disorder was
significantly higher in patients with cerebrovascular disorders, Parkinson's
syndrome (p < 0.01, respectively) and symptomatic epilepsy, hypertension (p <
0.05, respectively) as underlying disease/complication. Regarding medicated
drugs, H2 blockers were related to swallowing disorder (p < 0.05). It was
confirmed that patients who were judged as having swallowing disorder (including
suspected cases) by the water swallowing test, and patients with underlying
diseases and complication that may cause the disorder, and patients medicated
with drugs that may affect the swalowing ability require appropriate
management by medical care staff.
Feinberg, M.J., J. Knebl, J. Tully (1996). Prandial aspiration and
pneumonia in an elderly population followed over 3 years. Dysphagia,
11:104-109
Fucile S, Wright P, Chan I, Yee S, Langlais M, Gisel E. Functional
oral-motor skills: do they change with age? Dysphagia 1998;13:195-201
Jaradeh, S. (1994). Neurophysiology of swallowing in the aged.
Dysphagia, 9: 218-220
Nilsson, H., O. Ekberg, R. Olsson, B. Hintfelt (1996). Quantitative
aspects if swallowing in an elderly nondysphagic population. Dysphagia,
11:180-184
Steele C, Greenwood C, Robertson C et al. Mealtime difficulties in a
home for the aged: not just dysphagia. Dysphagia 12:45-50, 1997
Hier geht es zurück zur Übersicht.
6. Phagophobie
Phagophobie/Psychogene Aspekte der Dysphagie
Shapiro J, Franko DL,
Gagne A.: Phagophobia: a form of psychogenic
dysphagia. A new entity.
Ann Otol Rhinol Laryngol. 1997
Apr;106(4):286-90.
Abstract:
There is a group of patients presenting with either acute or chronic dysphagia
secondary to fear of swallowing. We have termed this entity phagophobia. It is
characterized by various significant swallowing complaints in the face of
normal findings on head and neck examination, oropharyngeal swallowing
videofluoroscopy, and standard barium swallow study. Ten patients who received
diagnoses of phagophobia after a full evaluation at our swallowing disorders
center are presented. Each patient was then evaluated by a psychologist, and
an attempt at therapy
was undertaken. We discuss the specific clinical
features, assessment, and treatment of this frequently misdiagnosed disorder.
de Lucas-Taracena MT, Ibarra I.:
"Swallowing
phobia: a case report"
Actas Esp Psiquiatr. 2001 Nov-Dec;29(6):411-3.
Abstract:
Choking phobia is characterized by fear and
avoidance of swallowing food, fluids or pills. It often appears in women after
an episode of choking on food. We present the case of an adolescent beginning
her phobia after a mononucleosis with severe dysphagia. Patient's solid
restriction raised concerns about differential diagnosis with eating
disorders. She was treated with psychoeducation, cognitive restructuring and
graduated exposure in vivo, achieving a total recovery.
Hyman PE.:
”Gastroesophageal
reflux: one reason why baby won't eat.”
J Pediatr. 1994 Dec;125(6 Pt 2):S103-9.
Abstract:
Gastroesophageal reflux (GER) is the movement of gastric contents retrograde
into the esophagus. Sometimes the refluxate is seen as emesis, but often
reflux is "silent," meaning that there are no discrete symptoms during an
episode. In adults, the most common symptom of GER is heartburn, whereas in
infancy excessive crying and malaise are symptoms that prompt investigation
for GER, with or without esophagitis. Symptoms of esophagitis in infancy may
include arching (hyperextension) of the torso and refusal of feedings. Tube
feedings may be required to treat infants with failure to thrive who refuse
oral feedings. Paradoxically, tube feedings increase the number of GER
episodes. A hypothetical explanation for refusal of food in infancy is that
pain with swallowing (odynophagia) or heartburn are consequences of peptic
esophagitis. As a result, infants will learn to refuse food if it hurts or if
they fear that it will hurt to eat. Another possible mechanism is visceral
hyperalgesia, a neuropathic condition in which prior experience changes
sensory nerves so that previously innocuous stimuli are perceived as painful.
Some infants may have especially sensitive sensory nerves in the upper
gastrointestinal tract, which predisposes visceral hyperalgesia to develop.
Thus pain occurs from luminal distension or acid reflux in the absence of
tissue damage. The evaluation of babies who won't eat includes a careful
history and physical examination to exclude the possibility of chronic
systemic illness. Refusal to feed is an unusual manifestation of a common
condition: GER disease. The initial tests for GER usually include a barium
swallow study to assess the upper gastrointestinal anatomy, endoscopy and
esophageal biopsy to assess esophagitis, and an intraesophageal pH study,
which is useful in "silent" reflux to quantitate the duration of esophageal
acid exposure and to correlate discrete symptom episodes with periods of
reflux. The treatment of infants and toddlers who refuse to eat because of
pain resulting from visceral hyperalgesia or reflux esophagitis involves
removing the pain associated with eating and making eating a pleasurable
experience. Treatment for esophagitis may include maintaining an upright
posture after meals and thickened feeds, medication to improve
gastrointestinal motility or to decrease acid secretion, or fundoplication.
Kohl F.:
“The pharyngeal anxiety syndrome: globus perception and pharyngeal sensations
as an oligosymptomatic abortive form of an anxiety disorder? Nosologic,
diagnostic and therapeutic aspects, illustrated with a case”
Psychiatr Prax. 1998 Sep;25(5):256-9.
Abstract:
Since the introduction of the modern psychiatric diagnosis systems anxiety
disorders have been intensively discussed. As clinical subtypes in panic
disorder the cardial type and the vestibular type are widely accepted. We
describe in a case report another of these subtypes, the pharyngeal type; it
is characterised by symptoms that are related to the pharynx such as feeling a
lump in the throat, swallow disturbance or pain in the pharynx region. It may
therefore be called "throat-anxiety syndrome" or "phagophobia".
Nosological implications are also
discussed.
Kamolz T, Bammer T, Pointner
R: ”Anxiety
disorder after laparoscopic refundoplication as a cause of dysphagia”
Surg Endosc. 2002 Feb;16(2):360-1. Epub 2001 Nov 16.
Abstract:
Side effects of laparoscopic antireflux surgery doubtless have a negative
effect on patients' satisfaction with surgical outcome and quality of life.
Until now, side effects of laparoscopic antireflux surgery such as dysphagia
have not been reported as associated with the origin of psychiatric disorders.
We report the case of a 71-year-old man who underwent laparoscopic
refundoplication because of a "slipping" Nissen 2 years after primary
intervention. After operation, the patient suffered from severe dysphagia and
required pneumatic dilation. In this patient, severe dysphagia has caused
panic disorder. Complete relief of dysphagia was achieved by single dilation.
In contrast, panic symptoms in relation to daily ingestion continued for at
least 6 weeks after surgery. A mild level of anxiety without panic symptoms
existed for the first 3 months after reoperation.
Ekberg O, Hamdy S, Woisard V, Wuttge-Hannig A, Ortega P:
”Social
and psychological burden of dysphagia: its impact on diagnosis and treatment”
Dysphagia. 2002 Spring;17(2):139-46.
Abstract:
The social and psychological impact of dysphagia has not been routinely
reported in large studies. We sought to determine the effects of dysphagia on
broad measures of the quality of life of patients and to explore the
relationship between the psychological handicaps of the condition and the
frequency of diagnosis and treatment. A total of 360 patients selected on the
basis of known subjective dysphagia complaints, regardless of origin, in
nursing homes and clinics in Germany, France, Spain, and the United Kingdom
were interviewed using an established questionnaire. Qualitative interviews
with a total of 28 health professionals were conducted to improve
understanding of the patient data in the context of each country. Over 50% of
patients claimed that they were "eating less" with 44% reporting weight loss
during the preceding 12 months. Thirty-six percent of patients acknowledged
receiving a confirmed diagnosis of dysphagia; only 32% acknowledged receiving
professional treatment for it. Most people with dysphagia believe their
condition to be untreatable; only 39% of the sufferers believed that their
swallowing difficulties could be treated. Eighty-four percent of patients felt
that eating should be an enjoyable experience but only 45% actually found it
so. Moreover, 41% of patients stated that they experienced anxiety or panic
during mealtimes. Over one-third (36%) of patients reported that they avoided
eating with others because of their dysphagia. In a largely elderly population
that might accept dysphagia as an untreatable part of the aging process,
clinicians need to be aware of the adverse effects of dysphagia on
self-esteem, socialization, and enjoyment of life. Careful questioning should
assess the impact of the condition on each patient's life, and patients should
be educated on their choices for treatment in the context of any coexisting
illness. Awareness of the condition, diagnostic procedures, and treatment
options must be increased in society and among the medical profession.
Gustafsson B.:
”The
experiential meaning of eating, handicap, adaptedness, and confirmation in
living with esophageal dysphagia”
Dysphagia. 1995 Spring;10(2):68-85.
Abstract:
This article is mainly based on interview studies of pensioners' (n = 62),
patients' (n = 19), and students' (n = 87) experiences of living with
longstanding esophageal dysphagia. The aim is to describe the experiential
meaning of dysphagic patients' lives by interpreting their experiences,
problems, and emotions and by specifying these into scales according to the
model of goal-directed action by Porn [43-49]. The experiential meaning will
be articulated in terms of attainment or nonattainment of goals in relation to
eating, handicap, adaptedness, and confirmation. In the experiential meaning
of eating, the emphasis is on the attainment of nourishing goals or goals
attained by means of food with desired hedonistic qualities and linked with
feelings of hope or no hope of a shared life. The experiential meaning of
handicap is interpreted as the dysphagic individual's experiences of an actual
nonattainment of eating goals due to swallowing disabilities and with
experiences of nonattainment of other important goals and related emotions;
for example, shame for human incompetence. The experiential meaning of
adaptedness is understood as the dysphagic individual's experiences of actual
capacity for goal attainments interpreted as a sense of control in the daily
living with dysphagia and linked with security, or in the negative case,
reduced self-esteem and feelings of panic or fear. The experiential meaning of
confirmation is interpreted as the dysphagic individual's experiences of
actual or potential repertoire for goal attainment, i.e., self-assessment
strengthened by evidence obtained in relationships linked with emotions of
hope of self-realization. In conclusion, a specific model for understanding
the dysphagic patient's concealment of dysphagia in the medical encounter has
been developed.
McNally RJ. :”Choking
phobia: a review of the literature”
Compr Psychiatry. 1994 Jan-Feb;35(1):83-9.
Abstract:
Choking phobia is characterized by fear and
avoidance of swallowing food, fluids, or pills. Most individuals with this
phobia suddenly acquire their fear after an episode of choking on food. Fear
of choking appears to occur somewhat more often in females than in males, and
has a variable age of onset ranging from childhood to old age. Its prevalence
is unknown. Choking phobia appears responsive to antipanic medication and to
certain cognitive and behavioral therapies.
Brown GE, Nordloh S, Donowitz AJ.:
"Systematic
desensitization of oral hypersensitivity in a patient with a closed head
injury."Dysphagia.
1992;7(3):138-41.
Abstract:
A 36-year-old man who had sustained a closed head injury displayed extreme
fear of being stimulated in the oral cavity, of being presented with foods,
and of swallowing. The patient's fear increased his muscle tone and
hypersensitivity in the facial and oral area, thereby preventing assessment of
his dysphagia. We describe the use of systematic desensitization to alleviate
the patient's fear thus allowing successful completion of a videofluoroscopic
barium swallow examination.
Stacher G.:
"Differential diagnosis of
psychosomatic deglutition disorders"
Wien Klin Wochenschr. 1986 Oct 10;98(19):658-63.
Abstract:
Symptoms of dysphagia and chronic vomiting often are categorized as being
elicited by psychogenic factors, when no explanation can be found by
fluoroscopic and endoscopic means. Psychogenic factors were also thought to be
of aetiological significance in 58 patients referred under the diagnoses
"psychogenic", "psychosomatic", and "functional" swallowing disorder,
"psychogenic vomiting", "conversion neurosis", "anorexia nervosa",
"psychosomatic disturbances in pregnancy", "cancer phobia", "cardiac phobia
(DaCosta syndrome)", and "depressive disorder" to the Psychophysiology Unit,
University of Vienna, for further evaluation. However, manometric, pH-metric,
and endoscopic investigations showed that all of these patients suffered in
fact from organic disorders: 36 from achalasia, 5 from vigorous achalasia, 5
from diffuse oesophageal spasms, 6 from lower oesophageal contraction
abnormalities, one from pharyngo-oesophageal dyscoordination, one from a
gastric ulcer ad cardiam, and 4 from gastro-oesophageal refluxes of whom one
also had a hypertonic upper oesophageal sphincter. These findings, together
with the fact that all concepts relating swallowing disorders to psychogenic
factors have remained purely speculative, show that it is not justifiable to
label dysphagic symptoms, for which no organic aetiology can be detected, as
"psychogenic" or "psychosomatic". Patients with such symptoms should be
studied by means of oesophageal manometry and/or pH-metry to reveal the nature
of their disorder and to enable adequate therapy.
Hier geht es zurück zur Übersicht.
7. Aspiration und Aspirationspneumonie
Aspiration und Aspirationspneumonie
Interventions to Prevent Aspiration Pneumonia in Older Adults: A
Systematic Review Mark B. Loeb Md, MSc, Marissa Becker MD, Angela Eady
MLS and Cindy Walker-Dilks MLS Journal of the American Geriatrics
SocietyVolume 51 Issue 7 Page 1018 - July 2003
Abstact:
A systematic review was conducted to assess the effectiveness of the
following interventions for prevention of aspiration pneumonia (AP) in older
adults: compensatory strategy/positioning changes, dietary interventions,
pharmacologic therapies, oral hygiene, and tube feeding. Data sources included
a key word search of the MEDLINE, EMBASE, Cochrane Library, CINAHL, and
HealthSTAR databases and hand searches of six journals. Reference lists of
relevant primary and review articles were searched. Studies included were
randomized, controlled trials (RCTs) enrolling adults aged 65 and older at
risk of and assessed for AP. Two investigators extracted data on population,
intervention, outcomes, and methodological quality. Of the 17 identified RCTs,
eight met the selection criteria, two addressed dietary management or
compensatory swallowing, two assessed pharmacological therapies, one assessed
oral hygiene, and three assessed tube feeding. None of the eight trials
reported use of blinding, and allocation concealment was unclear in five. Use
of amantadine prevented pneumonia in one trial of nursing home residents. The
antithrombotic agent cilostazol prevented AP in another trial but resulted in
excessive bleeding. Insufficient data exist to determine the effectiveness of
positioning strategies, modified diets, oral hygiene, feeding tube placement,
or delivery of food in preventing AP. Considering how common the problem of AP
is in older adults, larger, high-quality RCTs on the effectiveness of
preventive interventions are warranted.
Prevention of pneumonia in elderly stroke patients by systematic
diagnosis and treatment of dysphagia: an evidence-based comprehensive analysis
of the literature. Doggett DL, Tappe KA, Mitchell MD, Chapell R, Coates
V, Turkelson CM. Dysphagia. 2001 Fall;16(4):279-95.
Abstract:
We conducted a
systematic literature review and analysis of programs for evaluating
swallowing in order to prevent aspiration pneumonia. This article derives from
an evidence report on diagnosis and treatment of swallowing disorders (dysphagia)
in acute-car stroke patients prepared by us as an Evidence-based Practice
Center (EPC) under contract to the U.S. Agency for Healthcare Research and
Quality (AHRQ). Available evidence on the diagnosis and treatment of dysphagia
for preventing pneumonia is limited. We found reported pneumonia rates in one
historical controlled study of a program using bedside exams (BSE) for acute
stroke patients; one uncontrolled case series study of acute stroke
patient-reporting of swallowing difficulty; one controlled case series study
of videofluoroscopic study of swallowing (VFSS) for acute stroke patients; and
one historical controlled study of fiberoptic endoscopic examination of
swallowing (FEES) for patients referred for swallowing evaluation in
rehabilitation centers. Comparing these results with historical controls
indicates that implementation of dysphagia programs is accompanied by
substantial reductions in pneumonia rates. While all these methods appeared
effective, the small sizes of available studies did not allow determination of
the relative efficacy of BSE, VFSS, or FEES. Internetadresse zum Thema:
www.ahcpr.gov/clinic/epcsums/dyshsum.htm
Recent developments in diagnosis and intervention for aspiration and
dysphagia in stroke and other neuromuscular disorders. Doggett DL,
Turkelson CM, Coates V. Curr Atheroscler Rep. 2002 Jul;4(4):311-8
Abstract:
This review discusses the impact of the evidence-based report on dysphagia
diagnosis and treatment in stroke patients prepared in 1999 by ECRI under
contract with the Agency for Healthcare Research and Quality (AHRQ).
Subsequent research findings are highlighted and research design and reporting
problems in the field are discussed. Progress has been made toward
standardizing training and rating of videofluoroscopic studies of swallowing (VFSS);
however, a consensus does not yet exist. A randomized, controlled trial
demonstrated that treatment directed by fiber-optic endoscopic evaluation of
swallowing with sensory testing (FEESST) or VFSS resulted in approximately
equivalent pneumonia rates. These two different methods provide both
overlapping and complementary information. There is discussion of the research
design problems of mixed patients versus homogeneous populations, case-control
diagnostic studies, inappropriate calculations of diagnostic sensitivity/specificity
using imperfect "gold standards," the lack of concurrent control groups in
treatment studies, and the misuse of statistical significance tests and P
values in examining matching of patient characteristics in comparative studies
and in identifying important variables in regression analysis.
Aviv JE, Sacco RL, Thomson J, Tandon R, Diamond B, Martin JH, et al:
Silent laryngopharyngeal sensory deficits after stroke. Presented at the
annual meeting of the American Broncho-Esophagological Association; 1996 May.
Orlando, Florida
Ding, R., J.A. Logemann (2000). Pneumonia in stroke: a retrospective
study. Dysphagia, 15, 51-57
Ekberg O, Feinberg M: Clinical and demographic
data in 75 patients with near-fatal choking episodes. Dysphagia 1992;7:205-8
Feinberg, M.J., J. Knebl, J. Tully (1996). Prandial aspiration and
pneumonia in an elderly population followed over 3 years. Dysphagia,
11:104-109
Gelperin A: Sudden death in the elderly population from
aspiration of food. J Am Geriar Soc 1974;22:135-6
Gleeson, K., D. Eggli,
S. Maxwell (1997). Quantitive aspiration during sleep in normal subjects.
Chest, 111:1266-1272
Horner, J., S. Brazer, E. massey (1993).
Aspiration in bilateral stroke patients: a validation study. Neurology,
43:430-433
Johnson, E.R., S. McKenzie, A. Sievers (1993). Aspiration
pneumonia in stroke. A 74: 973-976
Kazi N, Mobarhan S. Enteral feeding
associated gastroesophageal reflux and aspiration pneumonia: a review.
Nutrition Revision 1996;54:324-8
Langmore, S.E., M. Terpenning, A. Schork, Y.
Chen, J. Murray, D. Lopatin, W. Loesche (1998). Predictors of aspiration
pneumonia:how important is dysphagia? Dysphagia, 13: 69-81
Logemann J,
Rademaker A, Pauloski B, Kahrilas P. Effects of postural change on
aspiration in head and neck surgical patients. Otolaryngology Head and
Neck Surgery 1994;110:222-7
Martin, B.J.W., M. Corley, H. Wood, D. Olson,
L.Golopol, M. Wingo, N. Kirmani (1994). The association of swallowing
dysfunction and aspiration pneumonia. Dysphagia, 9:1-6
Teasell, R.W., D.
Bach, M. McRae (1994). Prevalence of aspiration poststroke: a
restrospective analysis. Dysphagia, 9:35-39
8. Oberer Intestinalsphinkter
Oberer Intestinalsphinkter
Easterling C, Kern M, Nitschke T, Shaker R. Effect of a novel exercise
on swallowing function and biomechanics in tube fed cervical dysphagia
patients: a preliminary report. Paper presentation Dysphagia Research
Society, New Orleans, 1998
Haapaniemi JJ, Laurikainen EA, Pullkinen J,
Marttila R. Botulin Toxin in the treatment of cricopharyngeal dysphagia.
Dysphagia 16; 171-175, 2001
Kahrilas P. UES, LES: Similarities and
Differences. Dodds-Donner Lecture, Dysphagia Research Society, New
Orleans, 1998
Kelly J. Management of upper esophageal sphincter disorders:
indications and complications of myotomy. Am J Med 108 (6): 43S-46S, 2000
Logemann J, Pajak T, Pauloski B. Failure of cricopharyngeal myotomy to
improve dysphagia following head en neck cancer surgery. Paper Dysphagia
Research Society, New Orleans, 1998
Ravich W, Neumann S, Buchholz D, Jones B.
Botulinum Toxin injection for pharyngo-esophageal segment (PES) narrowing
in post-stroke dysphagia. Paper Dysphagia Research Society, New Orleans,
1998
Scolapio JS, Gostout CJ, Schröder KW. Dysphagia without endoscopically
evident disease: to dilate or not? Am J Gastroenterol 96; 327-330, 2001
Shaker R, Kern M, Bardan E, Taylor A, Stewart ET, Hoffmann RG, Arndorfer RC,
Hofmann C, Bonnevier J. Augmentation of deglutitive upper esophageal
sphincter opening in the elderly by exercise. Am J Physiol 272; 1518-1522,
1997
Sivaroa DV, Goyal RK. Functional anatomy and physiology of the upper
esophageal sphincter. Am J Med 108 (6): 27S-37S
Solt J, Bajor J, Moizs M,
Grexa E. Primary achalasia and its dilatation with balloon catheter.
Orv Hetil 42; 2287-2292, 2000
9. Apoplexie
Cerebrovaskulärer Vorfall (Apoplexie)
Aviv JE, Sacco RL, Thomson J, Tandon R, Diamond B, Martin JH, et al:
Silent laryngopharyngeal sensory deficits after stroke. Presented at the
annual meeting of the American Broncho-Esophagological Association; 1996 May.
Orlando, Florida Barer, D.H. (1989). The natural history and functional
consequences of dysphagia after hemispheric stroke. Journal of Neurology
Neurosurgery Psychiatry; 52, 236-241.
Dennis, M. (2000). Nutrition after
stroke. British Medical Bulletin, 56, 466-475.
DePippo, K.L., M. Hoals, M.
Reding, F. Mandel, M. Lesser (1994). Dysphagia therapy following stroke: a
controlled trial. Neurology, 44:1655-1660
Ding, R., J.A. Logemann (2000).
Pneumonia in stroke: a retrospective study. Dysphagia, 15, 51-57.
Elmståhl,
S., M. Bülow, O. Ekberg, M. Petersson, H. Tegner (1999). Treatment of
dysphagia improves nutritional conditions in stroke patients. Dysphagia,
14, 61-66.
Finestone, H.M., L.S. Greene-Finestone, E.S.|Wilson, R.W. Teasell
(1995). Malnutrition in stroke patients on the rehabilitation service and
at follow up: prevalence and predictors. Archives of Physical Medicine and
Rehabilitation, 76, 310-316.
Gordon, C. R.L. Hewer, D.T. Wade (1987).
Dysphagia in acute stroke. British Medical Journal, 295, 411-414.
Hamdy,
(1997). Explaining oropharyngeal dysphagia after unilateral hemispheric
stroke. Lancet, 350, 686-692.
Hamdy, S., J.C. Rothwell, Q. Aziz, D.G.
Thompson (2000). Organization and reorganization of human swallowing motor
cortex: implications for recovery after stroke. Clinical Science, 98,
151-157.
Holas, M.A., K.L. DePippo, M.J. Reding (1994). Aspiration and
relative risk of medical complications following stroke. Archives of
Neurology, 51, 1051-1053.
Horner J, F.G. Buoyer, M.J. Alberts, M.J. Helms
(1991). Dysphagia following brainstem stroke. Archives of Neurology,
48, 1170-1172.
Horner J, S.R. Brazer, E.W. Massey (1993). Aspiration in
bilateral stroke patients: a validation study. Neurology, 43: 430-433.
Horner, J., E. Massey, J. Riski, D. Lathrop, K. Chase (1988). Aspiration
following stroke: clinical correlates and outcome. Neurology, 38:1359-1362
James, A., K. Kapur, A. Barney Hawthorne (1998). Long-term outcome of
percutaneous endoscopic gastrostomy feeding in patients with stroke. Age
and aging. 27, 671-676.
Kidd, D., J. Lawson, R. Nesbitt, J. MacMahon (1995).
The natural history and clinical consequences of aspiration in acute stroke.
Quarterly Journal of Medicine, 88, 409-413.
Meng, N-H, T-G Wang, I-N Lien
(2000). Dysphagia in patients with brainstem stroke. American Journal
of Physical Medicine and Rehabilitation, 79, 170-175
Nilssen, H., O. Ekberg,
R. Olsson, B. Hindfelt (1998). Dysphagia in stroke: a prospective study of
quantative aspects of swallowing in dysphagic patients. Dysphagia,
13:32-38
Odderson, I.R., J. Keaton, B. McKenna (1995). Swallow management
in patients on an acute stroke pathway: quality is cost effective.
Archives of Physical and Medical Rehabilitation, 76:1130-1133
Perry, L., C.P.
Love, (2001). Screening for dysphagia and aspiration in acute stroke: a
systematic review. Dysphagia, 16, 7-18.
Rosenbek, J., J. Robbins, B.
Fishback, R. Levine (1991). Effects of thermal application on dysphagia
after stroke. Journal of Speech and Hearing research, 34:1257-1268
Smithard, D.G., P. O’Neill, C. Park, J. Morris, R. Wyatt, R. England, D.
Martin (1996). Complications and outcome after acute stroke. Does dysphagia
matter? Stroke, 27:1200-1204
Smithard, D.G., P. O’Neill, R. England, C.
Park, R. Wyatt, D. Martin, J. Morris (1997). The natural history of
dysphagia following a stroke. Dysphagia, 12:188-193
Teasell, R.W., D.
Bach, D. McRae (1994). Prevalence and recovery of aspiration poststroke: a
prospective analysis. Dysphagia, 9:35-39
10. FEES
FEES
Ajemian MS, Nirmul GB, Anderson MT, Zirlen DM, Kwasnik EM. Routine
fiberoptic endoscopic evaluation of swallowing following prolonged intubation:
implications for management. Arch Surg. 2001 Apr;136(4):434-7.
Abstract:
HYPOTHESIS: Fiberoptic endoscopic evaluation of swallowing (FEES) will
identify patients who are at high risk for pulmonary aspiration due to
swallowing dysfunction after prolonged intubation. Based on the results of
FEES, dietary recommendations can be made to decrease the incidence of
aspiration after prolonged intubation. DESIGN: Patients who were intubated for
at least 48 hours were evaluated for swallowing dysfunction by bedside FEES
within 48 hours of extubation. Differences in potential risk factors between
aspirators and nonaspirators were analyzed. Dietary recommendations were made
and patients were followed up for signs of clinically significant aspiration.
SETTING: Community teaching hospital. PATIENTS: Fifty-one consecutive patients
with no previously documented swallowing disorder who required a minimum of 48
hours of intubation for mechanical ventilation. INTERVENTIONS: Fiberoptic
endoscopic evaluation of swallowing was performed by a speech pathologist.
Initial diet orders were determined by results of the swallowing study. MAIN
OUTCOME MEASURES: Incidence of swallowing dysfunction following prolonged
intubation and incidence of clinically significant aspiration following
initiation of oral feeding. RESULTS: Incidence of swallowing dysfunction was
56% (27/48); 12 (25%) of 48 patients were silent aspirators. In comparing
aspirators with nonaspirators, no significant differences in potential risk
factors or comorbidities were seen. Nineteen (70%) of the 27 patients
aspirated with thin-consistency test liquids, and the other 8 (30%) with puree
consistency. No patients in this study group developed a clinically
significant aspiration following initiation of appropriately modified diets.
CONCLUSIONS: Fiberoptic endoscopic evaluation of swallowing identified
swallowing dysfunction in more than 50% of patients intubated for longer than
48 hours, many of whom are silent aspirators. Dietary recommendations based on
FEES results prevented clinically significant aspiration.
Lim SH, Lieu PK, Phua SY, Seshadri R, Venketasubramanian N, Lee SH, Choo PW.
Accuracy of bedside clinical methods compared with fiberoptic endoscopic
examination of swallowing (FEES) in determining the risk of aspiration in
acute stroke patients. Dysphagia. 2001 Winter;16(1):1-6.
Abstract:
This
prospective study was undertaken to determine the accuracy of bedside clinical
methods compared with fiberoptic endoscopic examination of swallowing (FEES)
for detecting aspiration in acute stroke patients. Fifty patients underwent an
examination of their ability to swallow 50 ml of water in 10-ml aliquots.
Later their oxygen saturation levels before and after swallowing 10 ml of
water were measured using a pulse oximeter. Oxygen desaturation of more than
2%, was considered to be clinically significant. All patients then underwent a
FEES assessment by a speech therapist and were followed up during their
inpatient stay for evidence of aspiration pneumonia. The oxygen desaturation
test had a sensitivity of 76.9% and specificity of 83.3% (chi2 = 18.154, p =
0.00002), while the 50-ml water swallow test had a sensitivity of 84.6% and
specificity of 75.0% (chi2 = 18.001, p = 0.00002). However, when these two
tests were combined into one test called "bedside aspiration," the sensitivity
rose to 100% with a specificity of 70.8% (chi2 = 27.9, p = 0.000001). Five
(10%) patients developed pneumonia during their inpatient stay. The relative
risk (RR) of developing pneumonia, if there was evidence of aspiration on FEES,
was 1.24 (1.03 < RR < 1.49). We conclude that the oxygen desaturation test
combined with the 50-ml water swallow test is suitable as a screening test to
identify all acute stroke patients at risk of aspiration for further
evaluation and management.
Leder SB, Karas DE. Fiberoptic endoscopic evaluation of swallowing in
the pediatric population. Laryngoscope. 2000 Jul;110(7):1132-6.
Abstract:
OBJECTIVE: To investigate the diagnostic and rehabilitative usefulness of
routine fiberoptic endoscopic evaluation of swallowing (FEES) in the pediatric
population. STUDY DESIGN: Prospective, consecutive, blinded. PATIENTS AND
METHODS: Thirty pediatric inpatients from a large, urban, tertiary care
teaching hospital participated. Their ages ranged from 11 days to 20 years (mean,
10 years and 4 months). In a random fashion, seven subjects were assessed with
both videofluoroscopic evaluation of swallowing (VFES) and FEES and 23
subjects were assessed solely with FEES. Diagnosis of dysphagia was determined
by spillage, residue, laryngeal penetration, and aspiration. Rehabilitative
strategies, e.g., positioning and modification of bolus consistencies, were
based on diagnostic findings. RESULTS: There was 100% agreement between the
blinded diagnostic results and implementation of rehabilitative strategies for
subjects randomly assigned to receive both VFES and FEES and for subjects who
received solely FEES. Of the 23 subjects assessed solely with FEES, 13 of 23
(57%) exhibited normal swallowing and 10 of 23 (43%) exhibited dysphagia. The
feeding recommendation for 4 of 10 subjects with dysphagia (40%) was for a
non-oral diet because of aspiration. FEES allowed for specific feeding
recommendations (i.e., bolus consistency modifications, positioning, and
feeding strategies) to reduce aspiration risk in 6 of 10 subjects with
dysphagia (60%). CONCLUSION: FEES can be used routinely to diagnose and treat
pediatric dysphagia in the acute care setting.
Leder SB. Fiberoptic endoscopic evaluation of swallowing in patients
with acute traumatic brain injury. J Head Trauma Rehabil. 1999
Oct;14(5):448-53.
Abstract:
Dysphagia and aspiration in intensive care unit patients
with acute traumatic brain injury (TBI) is a frequent and potentially
life-threatening problem. Any diagnostic technique used with this population,
therefore, must be able to be performed in a timely and efficient manner while
providing objective information on the nature of the swallowing problem. The
purpose of the present study was to investigate the utility of using the
fiberoptic endoscopic evaluation of swallowing (FEES) technique to diagnosis
pharyngeal stage dysphagia and determine aspiration status in patients who
presented with acute TBI. A total of 47 subjects were assessed with FEES.
Thirty of 47 (64%) subjects swallowed successfully and were able to take an
oral diet: 2 of 30 (7%) thickened liquids and puree consistencies, 8 of 30
(27%) a soft diet, and 20 of 30 (67%) a regular diet. Seventeen of 47 (36%)
subjects exhibited pharyngeal stage dysphagia with aspiration and were not
permitted an oral diet based on objective results provided by FEES. Of the 17
subjects who aspirated, 9 of 17 (53%) exhibited silent aspiration. Younger
subjects (mean age 34 years, 3 months) aspirated significantly less often than
older subjects (mean age 51 years, 8 months). No significant age difference
was observed for gender or between overt and silent aspirators. It was
concluded that FEES is an objective and sensitive tool that can be used
successfully to diagnose pharyngeal stage dysphagia, determine aspiration
status, and make recommendations for oral or nonoral feeding in patients with
acute TBI.
Colodny N. Interjudge and intrajudge reliabilities in fiberoptic
endoscopic evaluation of swallowing (fees) using the penetration-aspiration
scale: a replication study. Dysphagia. 2002 Fall;17(4):308-15.
Abstract:
This
study used Fiberoptic Endoscopic Evaluation of Swallowing (FEES(R)) to assess
the reliability of the Penetration-Aspiration Scale (PAS) using 79 swallows
and four judges in a replication of a study using videofluoroscopy (VFSS). The
swallows were diagnosed using FEES, which allowed for comparison between the
two techniques. The findings indicated that all categories of the PAS achieved
adequate reliability, both on intrajudge and interjudge assessments.
Reliabilities, with the exception of Scale Score 7, were higher in this study
than in the original study by Rosenbek and associates. Data analysis indicated
that judges were more highly consistent on second ratings compared with their
original ratings, indicating a learning curve on the PAS. In addition,
findings suggested that the FEES was more reliable on assessing penetration
than VFSS, but that VFSS was more reliable on the assessment of the various
severities of aspiration. The two techniques were equally effective in
discriminating between penetration and aspiration. This study found that FEES
was just as reliable as VFSS when using the PAS.
Leder SB, Espinosa JF. Aspiration risk after acute stroke: comparison of
clinical examination and fiberoptic endoscopic evaluation of swallowing.
Dysphagia. 2002 Summer;17(3):214-8.
Abstract:
Aspiration is an important variable
related to increased morbidity, mortality, and cost of care for acute stroke
patients. This prospective systematic replication study compared a clinical
swallowing examination consisting of six clinical identifiers of aspiration
risk, i.e., dysphonia, dysarthria, abnormal gag reflex, abnormal volitional
cough, cough after swallow, and voice change after swallow, with an
instrumental fiberoptic endoscopic evaluation of swallowing (FEES) to
determine reliability in identifying aspiration risk following acute stroke. A
referred consecutive sample of 49 first-time stroke patients was evaluated
within 24 hours poststroke, first with the clinical examination followed
immediately by FEES. The endoscopist was blinded to results of clinical
testing. The clinical examination correctly identified 19 subjects with
aspiration risk, when compared with the criterion standard FEES, but
incorrectly identified 3 patients as having no aspiration risk when they did.
The clinical examination incorrectly identified 19 subjects with aspiration
risk but determined correctly no aspiration risk in 8 patients who did not
exhibit aspiration risk on FEES. Clinical examination sensitivity = 86%;
specificity = 30%; false negative rate = 14%; false positive rate = 70%;
positive predictive value = 50%; and negative predictive value = 73%. It was
concluded that the clinical examination, when compared with FEES,
underestimated aspiration risk in patients with aspiration risk and
overestimated aspiration risk in patients who did not exhibit aspiration risk.
Careful consideration of the limitations of clinical testing leads us to
believe that a reliable, timely, and cost-effective instrumental swallow
evaluation should be available for the majority of patients following acute
stroke.
Broniatowski, M. (1998). Editorial: Fiberoptic endoscopic evaluation of
dysphagia and videofluoroscopy. Dysphagia, 13:22-23
Langmore, S.E., T.
McCulloch (1997). Examination of the pharynx and larynx and endoscopic
examination of pharyngeal swallowing. In Perlman, A.L., K. Schulz-Delrieu
(1997). Deglutition and its disorders. Anatomy, physiology, clinical
diagnosis and management. San Diego: Singular Publishing.
Leder, S.B., C.
Sasaki, M. Burrel (1998). Fiberoptic endoscopic evaluation of dysphagia to
identify silent aspiration. Dysphagia, 13:19-21
11. Stimm- und Sprachtherapie
Stimm- und Sprachtherapie
Bisch E, Logemann J, Rademaker A, Kahrilas P, Lazarus C. Pharyngeal
effects of bolus volume, viscosity and temperature in patients with dysphagia
resulting from neurologic impairment and in normal subjects. Journal of
Speech and Hearing Research 1994;37:1041-9
Fujiu M, Logemann J. Effect of a
tongue-holding maneuver on posterior pharyngeal wall movement during
deglutition. JSLHR 1996; 5:23-30
Lazarra G, Lazarus C, Logemann J.
Dyspagia 1986;1:73-77 Logemann J, Rademaker A, Pauloski B, Kahrilas P.
Otolaryngology Head and Neck Surgery 1994;110:222-7
Logemann J, Pauloski B,
Colangelo L, Lazarus C, Fujiu M, Kahrilas P. Effects of a sour bolus on
oropharyngeal swallowing measures in patients with neurogenic dysphagia.
Journal of Speech and Hearing Research 1995;38:556ff
Ohmae Y, Logemann J,
Kaiser P, Hanson D, Kahrilas P. Effects of two breath-holding maneuvers on
oropharyngeal swallow. Annals of Otology, Rhinology & Laryngology
1996;105:123-31
Rademaker A, Pauloski B, Colangelo L, Logemann J. Age and
volume effects on liquid swallowing function in normal women. Journal of
Speech and Hearing Research 1998;4:275-84
Rosenbek, J., J. Robbins, B.
Fishback, R. Levine (1991). Effects of thermal application on dysphagia
after stroke. Journal of Speech and Hearing research, 34:1257-1268
Shaker
R, Kern M, Bardan E, Taylor A, Stewart ET, Hoffmann RG, Arndorfer RC, Hofmann
C, Bonnevier J. Augmentation of deglutitive upper esophageal sphincter
opening in the elderly by exercise. Am J Physiol 272; 1518-1522, 1997
12. Arzneimittelbedingte Dysphagie
Arzneimittelbedingte Dysphagie
Sehr ausführlicher Original-Artikel von KM BALZER zum Thema "Drug induced
dysphagia:
http://www.mscare.org/journal/a0003/page_06.cfm
Campbell-Taylor I. Drugs, dysphagia, nutrition. Ontario: Ontario
College of Pharmacists;1996.
Fonda, D., J. Schwarz, S. Clinnick (1995).
Parkinsonian medication one hour before meals improves symptomatic swallowing:
a case study. Dysphagia, 10:165-166
Sliwa, J.A., S. Lis (1993).
Drug-injuced dysphagia. Archives of Physical Medicine and Rehabilitation,
74:445-447
Sokoloff, L.G., R. Pavlakovic (1997). Neuroleptic induced
dysphagia. Dysphagia, 12: 177-179
Stoschus, B., H. Allescher (1993).
Drug-induced dysphagia. Dysphagia, 8:154-159
13. Morbus Parkinson
Morbus Parkinson
A El Sharkawi, L Ramig,
J A Logemann, B R Pauloski, A W Rademaker,
C H Smith, A Pawlas, S Baum and C
Werner: Swallowing and voice effects of
Lee Silverman Voice Treatment (LSVT®): a pilot study
Correspondence to:
Dr J A Logemann, Northwestern University, Department of Communication Sciences
and Disorders, 2299 North Campus Drive, 3–358 Evanston, Illinois 60208, USA;
j-logemann@nwu.edu
Objective: To define the effects of Lee Silverman Voice Treatment
(LSVT® on swallowing and voice in eight patients with idiopathic
Parkinson's disease.
Methods: Each patient received a modified barium swallow (MBS)
in addition to voice recording before and after 1 month of LSVT®.
Swallowing motility disorders were defined and temporal measures of
the swallow were completed from the MBS. Voice evaluation included
measures of vocal intensity, fundamental frequency, and the
patient's perception of speech change.
Results: before LSVT®, the most prevalent swallowing motility
disorders were oral phase problems including reduced tongue control
and strength. Reduced tongue base retraction resulting in residue
in the vallecula was the most common disorder in the pharyngeal
stage of the swallow. Oral transit time (OTT) and pharyngeal
transit time (PTT) were prolonged. After LSVT®, there was an
overall 51% reduction in the number of swallowing motility
disorders. Some temporal measures of swallowing were also
significantly reduced as was the approximate amount of oral residue
after 3 ml and 5 ml liquid swallows. Voice changes after LSVT®
included a significant increase in vocal intensity during sustained
vowel phonation as well as during reading.
Conclusions: LSVT® seemingly improved neuromuscular control of
the entire upper aerodigestive tract, improving oral tongue and
tongue base function during the oral and pharyngeal phases of
swallowing as well as improving vocal intensity.
Pfeiffer RF. Gastrointestinal dysfunction in Parkinson's disease.
Lancet Neurol. 2003 Feb;2(2):107-16.
Abstract:
There is growing recognition that
gastrointestinal dysfunction is common in Parkinson's disease (PD). Virtually
all parts of the gastrointestinal tract can be affected, in some cases early
in the disease course. Weight loss is common but poorly understood in people
with PD. Dysphagia can result from dysfunction at the mouth, pharynx, and
oesophagus and may predispose individuals to aspiration (accidental inhalation
of food or liquid). Gastroparesis can produce various symptoms in patients
with PD and may cause erratic absorption of drugs given to treat the disorder.
Bowel dysfunction can consist of both slowed colonic transit with consequent
reduced bowel-movement frequency, and difficulty with the act of defecation
itself with excessive straining and incomplete emptying. Recognition of these
gastrointestinal complications can lead to earlier and potentially more
effective therapeutic intervention.
Volonte MA, Porta M, Comi G. Clinical assessment of dysphagia in early
phases of Parkinson's disease. Neurol Sci. 2002 Sep;23 Suppl 2:S121-2.
Abstract:
Dysphagia is a frequent symptom in parkinsonism, but it is less commonly
reported by patients with idiopathic Parkinson's disease (IPD), especially in
the early phases. Sixty-five patients with IPD were questioned about symptoms
of dysphagia and an objective swallowing test was administered. Reduced
swallowing speed for food and complaints of food sticking in the throat, wet
voice and cough after liquid intake and nocturnal sialorrhea were reported,
respectively, by 35%, 20% and 15% of patients. On objective examination,
oral-phase (facial, tongue and palatal musculature) abnormalities were found
in 70% of patients. Lingual transfer movements, mainly propulsion, and palatal
elevation were severely hypokinetic. Wet voice after liquid intake and cough
reflex after solid/liquid intake were detected in 40% of patients. On the
other hand, severe dysphagia with frequent food aspiration and chest
infections requiring antibiotics in the last 12 months was not found; cough
reflex was retained in all patients. On the basis of these results, a regular
assessment on swallowing abilities in patients with IPD is warranted in the
clinical setting because with simple dietary advice and a short rehabilitative
training, the quality of life in these patients can be improved.
Ertekin C, Tarlaci S, Aydogdu I, Kiylioglu N, Yuceyar N, Turman AB, Secil
Y, Esmeli F. Electrophysiological evaluation of pharyngeal phase of
swallowing in patients with Parkinson's disease. Mov Disord. 2002
Sep;17(5):942-9.
Abstract:
We studied the various physiological aspects of
oropharyngeal swallowing in Parkinson's disease (PD). Fifty-eight patients
with PD were investigated by clinical and electrophysiological methods that
measured the oropharyngeal phase of swallowing. All patients except 1 had mild
to moderate degree of disability score. Dysphagia was demonstrated in 53% of
all patients in whom the test of dysphagia limit was abnormal. All PD patients
with or without dysphagia displayed the following abnormalities: (1) the
triggering of the swallowing reflex was prolonged probably due to inadequate
bolus control in the mouth and tongue and/or a specific delay in the execution
of the swallowing reflex; (2) the duration of the pharyngeal reflex time was
extremely prolonged due to slowness of the sequential muscle movements,
especially those of the suprahyoid-submental muscles; (3) cricopharyngeal
muscle of the upper oesophageal sphincter was found to be
electrophysiologically normal; and (4) the electrophysiological phenomena in
PD patients could not be strongly correlated with the degree of the disability
and clinical score of the PD. It was concluded that various motor disorders of
PD have considerable influence on oropharyngeal swallowing: hypokinesia,
reduced rate of spontaneous swallowing, and the slowness of segmented but
coordinated sequential movements rather than any abnormalities in the central
pattern generator of the bulbar center. Some compensatory mechanisms in the
course of PD may explain the benign nature of swallowing disorder until the
terminal stage of the disease. Similarly, the swallowing problems of PD are
not only related with the dopamine deficiency; some other nondopaminergic
mechanisms may also be involved. Copyright 2002 Movement Disorder Society
Potulska A, Friedman A, Krolicki L, Jedrzejowski M, Spychala A.
Swallowing disorders in Parkinson's disease [Artikel in Polnisch ] Neurol
Neurochir Pol. 2002 May-Jun;36(3):449-56.
Abstract:
Impairment of swallowing is a
common symptom in advanced stage of Parkinson's disease and severe defect of
this function may cause aspiration pneumonia, problems with food intake and
cachexy. The aim of this study was to assess the reflex and oral, pharyngeal,
oesophageal phase of swallowing. Eleven patients with Parkinson's disease and
9 healthy subjects were investigated by electromyography (EMG) and oesophageal
scintigraphy. The study demonstrates delayed triggering of swallowing reflex
(543 +/- 84 ms in patients with PD vs. 230 +/- 66 ms in controls, p < 0.05)
and prolongation of laryngeal movement (1880 +/- 140 ms vs. 1349 +/- 154 ms, p
< 0.05). The prolongation of the oesophageal phase of swallowing with
predilection to retention of water in lower one/third part of esophagus (12.45
+/- 2.45 s vs. 6.45 +/- 1.18 s, p < 0.001) was observed. The dysphagia limit,
that is the maximum amount of water swallowed at once, was also evaluated (all
normal subjects are able to swallow 20 ml water or more at once). In the
studied patients with Parkinson's disease it was 4.5 +/- 0.86 ml. These
results evidently and objectively indicate the presence of swallowing
disorders in Parkinson's disease. Dysphagia was observed in all studied
patients, although only 8 of them complained about it. In other 3 cases the
impairment of swallowing was subclinical and it was connected with
prolongation of oesophageal phase.
Nagaya M, Kachi T, Yamada T, Igata A. Videofluorographic study of
swallowing in Parkinson's disease. Dysphagia. 1998 Spring;13(2):95-100.
Abstract:
We studied 16 patients with Parkinson's disease (PD) with dysphagia and 8
young and 7 elderly normal controls videofluorographically to evaluate the
nature of swallowing disorders in PD patients. In 13 patients, abnormal
findings in the oral phase were residue on the tongue or residue in the
anterior and lateral sulci, repeated pumping tongue motion, uncontrolled bolus
or premature loss of liquid, and piecemeal deglutition. Thirteen patients
showed abnormal findings in the pharyngeal phase, including vallecular residue
after swallow, residue in pyriform sinuses, and delayed onset of laryngeal
elevation. Ten of these patients also showed abnormal findings in both the
oral and pharyngeal phases. Aspiration was seen in 9 patients. The oral
transit duration was significantly longer in the patients with and without
aspiration than in the control subjects. The stage transition duration,
pharyngeal transit duration, duration of the upper esophageal sphincter (UES)
opening, and total swallow duration were significantly longer in the patients
with and without aspiration than in the young controls, but were not longer
than in the elderly controls. These durational changes in the pharyngeal phase
of swallowing were similar to those in the elderly controls. The findings
suggest that the disturbed motility in the oral phase of swallowing may be due
to bradykinesia. Although PD patients with dysphagia evince a variety of
swallowing abnormalities, the duration of pharyngeal swallowing may remain
within the age-related range until the symptoms worsen.
Bassotti G, Germani U, Pagliaricci S, Plesa A, Giulietti O, Mannarino E,
Morelli A. Esophageal manometric abnormalities in Parkinson's disease.
Dysphagia. 1998 Winter;13(1):28-31.
Abstract:
The gastrointestinal tract, and
especially the esophagus, is frequently involved in neurological diseases;
however, objective studies of gut motor function are few. We carried out an
esophageal manometric study in 18 patients with various stages of Parkinson's
disease (4 stage I, 4 stage II, 7 stage III, and 3 stage IV) to evaluate the
function of the viscus in this disease. Clinical assessment showed that 61%
complained of esophageal symptoms such as dysphagia, acid regurgitation,
pyrosis, and noncardiac chest pain. Manometric abnormalities were documented
also in 61% patients, and were represented by repetitive contractions,
simultaneous contractions, reduced LES pressure, and high-amplitude
contractions. However, only 33.3% of patients had both symptoms and manometric
abnormalities. We conclude that esophageal motor abnormalities are frequent in
Parkinson's disease, and may appear at an early stage of the disease.
Clarke CE, Gullaksen E, Macdonald S, Lowe F. Referral criteria for
speech and language therapy assessment of dysphagia caused by idiopathic
Parkinson's disease. Acta Neurol Scand. 1998 Jan;97(1):27-35.
Abstract:
OBJECTIVE:
To examine the prevalence of dysphagia in idiopathic Parkinson's disease (IPD)
in the outpatient setting and to determine what assessment criteria to use to
select patients with dysphagia for referral to speech and language therapists.
MATERIAL AND METHODS: Sixty-four patients with IPD and 80 age-matched controls
were interviewed in clinic about their swallowing history and an objective
swallowing test administered. All patients were assessed over the next few
weeks by an experienced speech and language therapist and dysphagia rated
according to a modified Rehabilitation Institute of Chicago Dysphagia Rating
Scale and a novel global rating scale. The ability of various clinic criteria
to predict patients with severe dysphagia were examined. RESULTS: Dysphagia
for food was found in 30% of patients, significantly more than in controls.
Swallowing speed and bolus volume were significantly lower in patients
compared with controls and were correlated with declining Hoehn and Yahr score.
Swallowing speed fell significantly on withdrawal of medication. The
therapist's global rating score and Chicago score declined with Hoehn and Yahr
score and duration of disease. However, only 10% of patients required dietary
advice and none needed gastrostomy or tracheostomy. Discriminant analysis
showed that various combinations of clinic selection criteria were no better
than the presence of dysphagia for food at predicting which patients had
significant dysphagia requiring advice from a therapist. CONCLUSIONS: Patients
with idiopathic Parkinson's disease should be questioned about dysphagia for
food on a regular basis and, if present, should be referred to a speech and
language therapist for further assessment and treatment. The outcome of this
protocol should be tested prospectively.
Hunter PC, Crameri J, Austin S, Woodward MC, Hughes AJ. Response of
parkinsonian swallowing dysfunction to dopaminergic stimulation. J Neurol
Neurosurg Psychiatry. 1997 Nov;63(5):579-83.
Abstract:
OBJECTIVES: To determine the
degree of dopaminergic response of swallowing dysfunction in Parkinson's
disease. METHODS: Fifteen patients with idiopathic Parkinson's disease and
symptomatic dysphagia were studied. All had motor fluctuations in response to
long term levodopa therapy. On two separate days, after overnight withdrawal
of all antiparkinsonian medication, a modified barium swallow using
cinefluoroscopy and different food consistencies was performed before and
after administration of oral levodopa and subcutaneous apomorphine. RESULTS:
Despite all patients having an unequivocal motor response to both agents,
there were few significant responses in any of the quantitative or qualitative
criteria of swallowing dysfunction assessed. The oral preparatory phase,
generally considered a more voluntary component of swallowing, showed a
response, but not with all consistencies. In a subgroup of patients the
pharyngeal phase time also improved. CONCLUSIONS: These findings suggest that
parkinsonian swallowing dysfunction is not solely related to nigrostriatal
dopamine deficiency and may be due to an additional non-dopamine related
disturbance of the central pattern generator for swallowing in the
pedunculopontine nucleus or related structures in the medulla.
Fuh JL, Lee RC, Wang SJ, Lin CH, Wang PN, Chiang JH, Liu HC. Swallowing
difficulty in Parkinson's disease. Clin Neurol Neurosurg. 1997
May;99(2):106-12.
Abstract:
Dysphagia is a frequent and potentially serious
complication of Parkinson's disease (PD). We examined the oropharyngeal
swallowing ability in 19 PD patients (15 men and 4 women, mean age 68.42 years,
mean Hoehn and Yahr stage 1.8) using modified barium swallow before and after
administering oral levodopa (in combination with benserazide). Twelve (63.2%)
patients demonstrated objective evidence of swallowing abnormalities; although
only six patients (31.6%) had subjective complaints. Vallecula sinus and
pyriform sinus residues were the most frequent abnormalities (47.4% and
42.1%); followed by delayed swallowing reflex (26.3%). Three patients
demonstrated silent aspiration. In the 12 patients with abnormal swallowing,
six (50%) showed objective improvement after levodopa treatment, while the
remaining six showed no change. Of the former group of six, one patient showed
improvement in the oral phase, but deterioration in the pharyngeal phase. We
concluded that PD patients had a high percentage of objective swallowing
abnormalities which could be reduced in half of the patients through the
administration of levodopa treatment.
Leopold NA, Kagel MC. Laryngeal deglutition movement in Parkinson's
disease. Neurology. 1997 Feb;48(2):373-6.
Abstract:
Laryngeal muscle function is
defective in Parkinson's disease (PD) patients; the intrinsic group (vocal
cords) is defective during phonation and the extrinsic group (laryngeal strap
muscles) is slow during deglutition. There are no studies of vocal cord
motility during deglutition in PD. We investigated laryngeal motility during
deglutition in 71 patients with PD in a videofluoroscopic swallowing study.
Patients were subdivided into two groups by the Hoehn and Yahr disability
scale, stages II and III (n = 38) and stages IV and V (n = 33). At least one
abnormality of laryngeal movement was present in 68 of 71 patients (95.8%);
most patients had multiple abnormalities. There was statistically significant
slowing of vertical laryngeal excursion; true vocal cord closure; or delayed,
incomplete, or absent opening of the true vocal cords. Patients with more
advanced disease manifested more deficits of laryngeal movement. Laryngeal
dysmotility in PD may be related to defective descending basal ganglionic
control of medullary deglutory and phonatory motor functions.
Bashford G, Bradd P. Drug-induced Parkinsonism associated with dysphagia
and aspiration: a brief report. J Geriatr Psychiatry Neurol. 1996
Jul;9(3):133-5.
Abstract:
Idiopathic Parkinsonism is a well-recognized cause of
dysphagia and resultant aspiration. Symptoms and signs attributable to
dopaminergic underactivity after administration of antipsychotic medication
are commonly seen in elderly patients. We report a case of a 74-year-old woman,
without prior symptoms of Parkinsonism or dysphagia, who presented with the
temporal association of both after administration of trifluoperazine
hydrochloride. Dysphagia is a potentially life-threatening complication of
drug-induced parkinsonism. Its early recognition allows treatment by simple
medical, physical, and dietary manipulations.
Ali GN, Wallace KL, Schwartz R, DeCarle DJ, Zagami AS, Cook IJ.
Mechanisms of oral-pharyngeal dysphagia in patients with Parkinson's disease.
Gastroenterology. 1996 Feb;110(2):383-92.
Abstract:
BACKGROUND & AIMS:
Oral-pharyngeal dysphagia in Parkinson's disease is well recognized. The aim
of this study was to establish the mechanisms of oral-pharyngeal dysphagia in
these patients. METHODS: Using simultaneous videoradiography and pharyngeal
manometry, we studied 19 patients with Parkinson's disease (12 with
oral-pharyngeal dysphagia and 7 without oral-pharyngeal dysphagia) and
compared them with 23 healthy controls. RESULTS: the clinical severity of
Parkinson's disease predicted neither the presence nor the severity of
dysphagia. Minor alterations in oral function were common in controls and
patients, but pharyngeal dysfunction was significantly more prevalent in
patients. Incomplete upper esophageal sphincter (UES) relaxation was present
in 4 patients (21%), all of whom showed increased hypopharyngeal intrabolus
pressure, but not all of whom had a diminished UES opening. The patients had a
reduced UES diameter (P = 0.004) and a higher intrabolus pressure compared
with the controls (P = 0.007). Pharyngeal contraction pressures were lower in
patients, but 6 patients with dysphagia and an abnormal pharyngeal wall motion
had normal peak pressures. CONCLUSIONS: An incomplete UES relaxation and a
reduced UES opening, both associated with high intrabolus pressure, are
prevalent in Parkinson's disease. Oral-pharyngeal dysphagia in Parkinson's
disease is multifactorial, with the majority of patients showing oral and
pharyngeal dysfunction, even before the clinical expression of dysphagia.
Impaired pharyngeal bolus transport is the major determinant of dysphagia.
Coates C, Bakheit AM. Dysphagia in Parkinson's disease. Eur Neurol.
1997;38(1):49-52.
Abstract:
The prevalence of dysphagia and its relationship to the
nutritional status of the subject was examined in 53 patients with Parkinson's
disease (PD). Forty-three patients (81%) had swallowing difficulties but this
was mild in most of them. The nutritional status of patients with PD was
similar to that of age- and sex-matched control subjects. Disease duration and
severity correlated with the severity of dysphagia. The study also identified
tremor and speech disturbances as the main predictors of dysphagia in PD.
Nilsson H, Ekberg O, Olsson R, Hindfelt B. Quantitative assessment of
oral and pharyngeal function in Parkinson's disease. Dysphagia. 1996
Spring;11(2):144-50.
Abstract:
Oral and pharyngeal dysfunction is common in
Parkinson's disease. To reveal the frequency of swallowing dysfunction and
correlate swallowing dysfunction with locomotor disturbances, we studied 75
patients with Parkinson's disease staged I-IV according to the Hoehn and Yahr
score. We assessed oral and pharyngeal swallow during optimal medication by a
quantitative test of swallowing (the ROSS test) measuring the suction pressure,
bolus volume, swallowing capacity, and time for important events in the
swallowing cycle. We found abnormal results in 7/12 patients (58%) in stage 1
of the Hoehn and Yahr score, in 13/14 patients (93%) in stage 2, in 29/32
patients (91%) in stage 3, and in 16/17 patients (94%) in stage 4. Abnormal
test results in stages, 1, 2, and 3 were seldom related to swallowing
difficulties noticed by the patients. In advanced disease (Hoehn and Yahr
stage 4), the abnormal results were often considerable, with swallowing
difficulties obvious to the patient. Two of 17 patients coughed during or
immediately after the test and 3/ 17 patients were unable to complete the
test. The degree of swallowing disturbance increased during stress (forced,
repetitive swallow). The Hoehn and Yahr score and the results in the ROSS test
did not correlate, indicating that swallowing disturbances are due to
nondopaminergic degeneration. Silent swallowing impairment may interfere with
the nutrition and quality of life in Parkinson's disease, thus it is of
interest to monitor this in clinical practice.
Leopold NA, Kagel MC. Prepharyngeal dysphagia in Parkinson's disease.
Dysphagia. 1996 Winter;11(1):14-22.
Abstract:
Dysphagia in patients with Parkinson's
disease (PD) is most often attributed to pharyngeoesophageal motor
abnormalities. In our study of patients with idiopathic PD, attention was
focused on prepharyngeal symptoms and motor functions. Using the Hoehn and
Yahr disease severity scale, patients were grouped into those with
mild/moderate disease [subgroup I (n = 38)] and those with advanced disease [subgroup
II (n = 34)]. Dysphagia symptoms were present in 82% of all patients, but
subgroup I patients voiced significantly more complaints. Conversely, many
prepharyngeal abnormalities of ingestion, including jaw rigidity, impaired
head and neck posture during meals, upper extremity dysmotility, impulsive
feeding behavior, impaired amount regulation, and lingual transfer movements
were statistically more frequent in subgroup II patients. Impaired mastication
and oral preparatory lingual movements were the most common aberrations
observed during dynamic videofluoroscopy (48/71), with most patients being
concordant for both. The motor disturbances of ingestion reported herein
reflect the disintegration of volitional and automatic movements caused by
PD-related akinesia, bradykinesia, and rigidity.
Johnston BT, Li Q, Castell JA, Castell DO. Swallowing and esophageal
function in Parkinson's disease. Am J Gastroenterol. 1995
Oct;90(10):1741-6.
Abstract:
Dysphagia and drooling of saliva are frequent symptoms
in Parkinson's disease (PD), occurring in one-half and three-quarters of all
patients, respectively. Aspiration related to swallowing is a major cause of
morbidity and mortality in PD. Defects in oral, pharyngeal, and esophageal
phases of swallowing have been documented in patients with PD, and these
defects precede symptoms. This paper reviews the current knowledge concerning
swallowing abnormalities in PD. The pathogenesis of dysphagia and drooling of
saliva is multifactorial, involving cognitive and psychological changes in
addition to abnormalities of the extrapyramidal and autonomic nervous systems.
Videofluoroscopic imaging of the upper esophageal sphincter and pharynx during
mastication and swallowing has been the basis of our understanding of the
mechanical malfunction present in patients with PD. Manometric abnormalities
of the esophageal body and lower esophageal sphincter have also been
documented. The use of combined manofluoroscopy to examine the upper
esophageal sphincter and pharynx in PD offers great promise both in
understanding the defects and directing therapy. Voluntary airway protection
techniques may reduce aspiration, but they need to be tested in a clinical
study. Such maneuvers may reduce the morbidity seen in PD.
Bine JE, Frank EM, McDade HL. Dysphagia and dementia in subjects with
Parkinson's disease. Dysphagia. 1995 Summer;10(3):160-4.
Abstract:
This study
reviewed the medical records of 19 patients with a diagnosis of Parkinson's
disease listed on the death certificate who died between June 1985 and July
1990. The presence or absence of dementia separated the patients into two
groups. The study examined the age at time of death, number and type of
secondary diagnoses, frequency of dysphagia diagnosis, and therapeutic dietary
differences. The presence of dementia did not influence the age at time of
death. Dysphagia was a common diagnosis for each group. Differences in
treatment of dysphagia were found to be dependent on the presence or absence
of dementia.
Hartelius L, Svensson P. Speech and swallowing symptoms associated with
Parkinson's disease and multiple sclerosis: a survey. Folia Phoniatr Logop.
1994;46(1):9-17.
Abstract:
A survey of approximately 460 patients with Parkinson's
disease (PD) or multiple sclerosis (MS) shows that speech and swallowing
difficulties are very frequent within these groups. Seventy percent of the PD
patients and 44% of the MS patients had experienced impairment of speech and
voice after the onset of their disease. Forty-one percent of the PD patients
and 33% of the MS patients indicated impairment of chewing and swallowing
abilities. The speech disorder was regarded as one of their greatest problems
by 29% of the PD patients and by 16% of the MS patients. Only a small number
of patients, 3% of the PD and 2% of the MS group, had received any speech
therapy.
Bine, J.E., E. Frank, H. McDade (1995). Dysphagia and dementia in
subjects with parkinson’s disease. Dysphagia, 10:160-164
Clarke, C.E., E.
Gullaksen, S. MacDonald, F. Lowe (1998). Referral criteria for speech and
language therapy assessment of dysphagia caused by idiopathic Parkinson’s
disease. Acta Neurologica Scandinavia, 97:27-35
Fonda, D., J. Schwarz, S. Clinnick (1995). Parkinsonian medication one hour before meals improves
symptomatic swallowing: a case study. Dysphagia, 10:165-166
Kirshner, H.
(1997). Editorial:Disorders of the pharyngeal and esophageal stages of
swallowing in Parkinson’s disease. Dysphagia, 12:19-20
Leopold. N.A., M.
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Nagaya, M., T. Kachi, T. Yamada,
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Parkinson’s disease. Dysphagia, 11:144-150
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15. Ernährung
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N Engl J Med. 2003 Jul 24;349(4):359-65.
Abstract:
BACKGROUND: Voluntary refusal of
food and fluids has been proposed as an alternative to physician-assisted
suicide for terminally ill patients who wish to hasten death. There are few
reports of patients who have made this choice. METHODS: We mailed a
questionnaire to all nurses employed by hospice programs in Oregon and
analyzed the results. RESULTS: Of 429 eligible nurses, 307 (72 percent)
returned the questionnaire, and 102 of the respondents (33 percent) reported
that in the previous four years they had cared for a patient who deliberately
hastened death by voluntary refusal of food and fluids. Nurses reported that
patients chose to stop eating and drinking because they were ready to die, saw
continued existence as pointless, and considered their quality of life poor.
The survey showed that 85 percent of patients died within 15 days after
stopping food and fluids. On a scale from 0 (a very bad death) to 9 (a very
good death), the median score for the quality of these deaths, as rated by the
nurses, was 8.On the basis of the hospice nurses' reports, the patients who
stopped eating and drinking were older than 55 patients who died by
physician-assisted suicide (74 vs. 64 years of age, P<0.001), less likely to
want to control the circumstances of their death (P<0.001), and less likely to
be evaluated by a mental health professional (9 percent vs. 45 percent,
P<0.001). CONCLUSIONS: On the basis of reports by nurses, patients in hospice
care who voluntarily choose to refuse food and fluids are elderly, no longer
find meaning in living, and usually die a "good" death within two weeks after
stopping food and fluids. Copyright 2003 Massachusetts Medical Society
Campbell-Taylor I. Drugs, dysphagia, nutrition. Ontario: Ontario
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awareness of their disability after stroke represents an important aspect of
functional recovery. Our study aimed to assess whether patient awareness of
the clinical indicators of dysphagia, used routinely in clinical assessment,
related to an appreciation of
a
swallowing problem
and how this awareness influenced swallowing performance and outcome in
dysphagic stroke patients. Seventy patients were studied 72 h post hemispheric
stroke. Patients were screened for dysphagia by clinical assessment, followed
by a timed water swallow test to examine swallowing performance. Patient
awareness of dysphagia and its significance were determined by detailed
question-based assessment. Medical records were examined at three months.
Dysphagia was identified in 27 patients, 16 of whom had poor awareness of
their dysphagic symptoms. Dysphagic patients with poor awareness drank water
more quickly (5 ml/s vs. <1 ml/s, p = 0.03) and took larger volumes per
swallow (10 ml vs. 6 ml, p = 0.04) than patients with good awareness. By
comparison, neither patients with good awareness or poor awareness perceived
they had a swallowing problem. Patients with poor awareness experienced
numerically more complications at three months. Stroke patients with good
awareness of the clinical indicators of dysphagia modify the way they drink by
taking smaller volumes per swallow and drink more slowly than those with poor
awareness. Dysphagic stroke patients, regardless of good or poor awareness of
the clinical indicators of dysphagia, rarely perceive they have a swallowing
problem. These findings may have implications for longer-term outcome, patient
compliance, and treatment of dysphagia after stroke.