James L. Coyle on Kagel

Marion Kagel, in the late 80’s and 90’s, described a tactic in which thermal (cold) gustatory (taste) stimulation was used to treat dysphagia. I believe they presented some of this data at the first of second DRS meeting in Milwaukee. It spawned the use of Italian lemon ice in the management of dysphagia. I still see the stuff in the freezers of the nursing units of some of the sites in which I see patients. I don’t know if they published their results.

Logemann et al. (1995) looked at the sour bolus effects on swallowing and others have investigated the combined effects of thermal, gustatory, and tactile/mechanical stimulation on swallowing (Sciortino, Liss, Case, Gerritsen, & Katz, 2003) using different methods and reporting varying degrees of effects on different outcomes. I’m almost certain others have looked at these things too. Logemann’s group flavored barium with a sour taste (lemon juice I think) for MBS swallows with and without the sour bolus, in dysphagic patients, and analyzed the traditionally measured biomechanical swallow variables. Sciortino’s group injected water into the mouths of normals after stimulating the faucial pillars (anterior) with the various combinations of thermal, tactile/mechanical, and taste stimuli.

James L. Coyle

University of Pittsburgh

Reference List

Logemann, J. A., Pauloski, B. R., Colangelo, L., Lazarus, C., Fujiu, M., & Kahrilas, P. J. (1995). Effect of a sour bolus on oropharyngeal swallowing measures in patients with neurogenic dysphagia. Journal of Speech and Hearing Research, 38, 556-563.

Sciortino, K., Liss, J. M., Case, J. L., Gerritsen, K. G., & Katz, R. C. (2003). Effects of mechanical, cold, gustatory, and combined stimulation to the human anterior faucial pillars. Dysphagia, 18, 16-26.

Bedside Swallowing Evaluation Components

Lip closure : oral receipt and containment; ability to suck (intraoral pressure)
Tongue movement: receipt of bolus, preparation of bolus, control and transport of bolus, clearance
Pharyngeal swallow response: Occurs? Appears timely, delayed
Laryngeal rise: Occurs? Appears brisk or sluggish?
Number of swallows per bolus: One or several? May indicate pharyngeal clearance
Voice quality: immediately prior to bolus presentation and after swallow; also monitor for later changes
Cough/throat clear: present or absent

Length of meal: Timely or prolonged?
Patient complaints: What? When?

The Human Brain

Estimating Risk of Pneumonia

James L. Coyle of the University of Pittsburgh wrote on the Dysphagia List-Serve:

"Eisenhuber et al (2002) developed a three point scale, using the height of retention in the vallecular and pyriform sinuses, as scale values.

A score of 1 corresponded to “less than 25% of the height” of the cavity described, 2 to “25-50% height”, and 3 to “>50% height”. They adapted a rating system published earlier by Perlman et al. (1994) by taking the published height values and attributing the values in the 3 point scale to the three measures created by Perlman.

They then used videofluoroscopy to determine whether pharyngeal retention seen on fluoroscopic images was predictive of laryngeal penetration or aspiration. They did not differentiate between the two (penetration, aspiration), instead lumping them together. This makes it difficult for the reader to know with certainty which outcome (penetration, aspiration) should be expected. They also lumped vallecular and pyriform sinus retention together in the attribution of aspiration/penetration risk however 83% of their patients had retention in both.

At any rate, The score “3” for pharyngeal retention was significantly more likely (about 4 to 1 odds of higher likelihood) to be followed by laryngeal penetration or aspiration than scores of 1 or 2. One finding that is a bit easier to swallow (ha ha) was that 93% of patients with pharyngeal retention (valleculae or pyriform sinuses or both) exhibited laryngeal penetration or aspiration whereas only 33% of patients without retention exhibited penetration or aspiration.

Robbins et al. (1999) used the penetration aspiration scale to differentiate between normals, and two groups of disordered swallowers (stroke, head and neck cancer). They found that 21% of normals exhibited high laryngeal penetration (no deeper than the vestibule-PAS scores of 2 or 3). Therefore deep penetration (to vocal folds) is not normal (nor is aspiration).

Combining the two measures, one can attribute risk of laryngeal penetration or aspiration to the height of pharyngeal retention, and the risk of inhalation of swallowed material to the severity of laryngeal penetration and aspiration. Added to the other host risk factors predisposing a patient to pneumonia, the clinician can generate a reasonable likelihood of pneumonia.

We use the two scales together to attribute risk associated with the dysphagia and discuss the additional risk factors to estimate pneumonia risk."

James L. Coyle

University of Pittsburgh

Reference List

Eisenhuber, E., Schima, W., Schober, E., Pokieser, P., Stadler, A., Scharitzer, M. et al. (2002). Videofluoroscopic assessment of patients with dysphagia: pharyngeal retention is a predictive factor for aspiration. American Journal of Roentgenology, 178, 393-398.

Perlman, A. L., Booth, B. M., & Grayhack, J. P. (1994). Videofluoroscopic predictors of aspiration in patients with oropharyngeal dysphagia. Dysphagia, 9, 90-95.

Robbins, J. A., Coyle, J. L., Rosenbek, J. C., Roecker, E. B., & Wood, J. L. (1999). Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale. Dysphagia, 14, 228-232.

Written Word Finding

Sometimes a person who is unable to look at an object and subsequently name it can look at the written word associated with that object, read it aloud correctly, and then verbally answer the question, "What is this?" with the name of the object.

So, you show a photograph of a cup. The person says, "glass." You show a list of written words, one of which is "c-u-p." The person is able to locate the correct word, and read it aloud. Then you show the photograph again, and ask, "What is this?" and the person correctly verbalizes "cup."

Remember T.E.E.?

If you recall trans-esophageal echocardiogram posts, then also recall that the AOS vs. phonemic paraphasia patient was undergoing that procedure the day we were working with him...

Do you think this patient might have come out of that procedure with a new swallowing problem?

Dysarthria Treatment

In order to increase the length of a response, ask: "Tell me what you like about __________(cookies, for example)" rather than "What kind of cookies do you like?"

During establishment of a new habit such as pacing, do not tell the patient "You don't need to use your board for this." Rather, give this sort of feedback: "When you use your pacing board, you slow down and you are so much easier to understand."

Use "Think slow" to assist in internalization of a slow speech rate as opposed to "slow down" which is an external cue.

Expect to need to use "lip reading" with most if not all patients with dysarthria.

AOS or Phonemic Paraphasias; Anterior vs. Posterior Lesions?

To ponder:

Errors: v/b as in tavle for table
sh/ch as in share for chair or wash for watch
d/t as in dime for time
s/sh as in sip for ship
sh/j as in Shawn for John

vowels tending toward schwa

superior awareness of errors with multiple and sometimes successful attempts
to correct

errors consistent across tasks and within same task

Is this more consistent with apraxia of speech or phonemic paraphasia?

SHAKER Exercise References

Several references for Shaker Exercise:

Easterling C, Grande B, Kern M, Sears K, Shaker R: Attaining and maintaining isometric and isokinetic goals of the "Shaker" Exercise. Dysphagia 20: 133-138, 2005

Easterling C, Kern M, Nitzsche T, Grande B, Kazandjian M, Dikeman K, Massey BT, Shaker R: Restoration of oral feeding in 27 tube fed patients by the Shaker Exercise. Dysphagia 10:66-74, 1999.


Shaker R, Easterling C, Kern M, Nitschke T, Massey B, Daniels S, Grande B, Kazandjian M, Dikeman K: Rehabilitation of swallowing by exercise in tube fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology 122:1314-1321, 2002.

Tracking Data

Suggestion: As we discussed day before yesterday, you may find it helpful to chart a patient's progress via a plot graph or chart.

Another use of this sort of graph is feedback for the patient, assuming that progress is being made.

I used to track my Goodwill Industry clients' productivity on individualized charts set at each person's work station. Made a huge difference in motivation, believe it or not.

"Normal" Laryngeal Penetration

James L. Coyle (University of Pittsburgh) wrote on the Dysphagia List-Serve:

"Robbins et al. (1999) used the PA {Penetration/Aspiration} Scale to differentiate normal from abnormal airway protection, and was written by the same group of authors of the original Penetration Aspiration Scale paper (Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996).

They found that all laryngeal penetration events in this group of 95 healthy subjects, showed penetration no more deeply than the laryngeal vestibule. All of these "penetration" events (55 events out of 284 swallows) were scored {as a} 2 (material enters the airway, remains above vocal folds, no contrast is visible in larynx after the swallow) or 3 (same anatomic "level" as 2, but with visible postprandial laryngeal residue). There were no 4 or 5 scores (material contacts the vocal folds without (4) or with(5) visible laryngeal postprandial residue). A single aspiration event was observed in the old group only (PAS score = 7, aspiration with responsive cough that did not clear tracheal residue).

Events...described as transient would probably be scored 2 and 4 on the PA scale because no residue is left behind in the larynx, whereas 3 and 5 (4 and 5-material contacts the vocal folds) indicate visible laryngeal postprandial residue. The scale was published in an effort to standardize these descriptions of swallowing airway compromise viewed with videofluoroscopic instrumentation.

Reference List

Rosenbek, J. C., Robbins, J. A., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetration-aspiration scale. Dysphagia, 11, 93-98."

My comments: Post-prandial usually refers to "after the meal," but I think J.L. Coyle is referring to post-swallow residue remaining in the laryngeal vestibule here.

Oral Stimulation

With some patients, even though they are awake and even alert, they are not responding to oral instructions such as "open your mouth," etc.

You can use a dry or moistened toothette to stimulate oral opening by stroking the lower and/or upper lips. You may be able to gently enter the mouth with the toothette along the inner cheek or along the gumlines. It may even be possible to stroke the tongue blade. As you perform these actions, watch your patient to determine tolerance, sensation, and any responses.

To further provide oral stimulation, you may also use the spoon to stroke the lips or the area of the cheek or chin around the lips. Before placing a food item in the mouth, you may want to put a little on the lower lip to see if the patient will lick it off indicating sensation is relatively intact. You have also determined that the tongue will protrude at least a little.

If the patient does not close around the spoon with presentation of liquids, pouring the liquid (very small amount) onto the tongue tip may then elicit lip closure. Be prepared to suction this liquid from the mouth if the patient does not handle well.

Applying pressure with the bowl of the spoon to the tongue blade may also assist in the cupping of the tongue for oral preparation. Letting go of the spoon also may assist the patient to close his or her mouth around the spoon -- appears to be a typical response to this technique.

Just some thoughts...

Medical Terms

What do the following terms mean?

Cephalopathy
Ascites

Adult Clinical Rotations: Student Presentation Guidelines

Adult Clinical Rotations

Student Presentation Guidelines

Description: Students will be required to present a clinical topic to the adult speech pathologists. Oral and written components are required.

Topics: Teach us something new! Maybe a disorder you had an experience with during your rotation (something we could learn more about); patient and/or family information packets; or a treatment strategy. If you decide to present a treatment strategy, please include the following information: treatment efficacy, cost efficiency, availability, reliability, etc. If you have difficulty choosing a topic, ask your supervisor for suggestions.

Written requirement: Please prepare a summarized handout for clinicians (1-2 pages) or a packet for patients/families. Include references. Do not print something directly from a website. You should organize this information on your own. If creating a Pt/family packet, provide helpful web sites, phone numbers, support groups, etc.

Oral requirement: You will be given approximately 5-7 minutes including a question-answer period. This is not a great deal of time, so plan accordingly.

Date: Presentations will be Tuesday, November 6th from 12:00-12:45pm.

Location: 11^th floor of Rutledge Towers (ENT conference room). Please bring your lunch.