Parkinson's Disease

"I don’t see anything in the description suspicious for a CN V3 (mandibular nerve) injury (was there a sensory impairment on the right side? V3 carries sensory fibers to the lower 1/3 of the face) except the jaw droop at rest which may just be his posture. Tongue to right would be right XII and palate paresis with hypernasality would be X. Also you would have to figure out what type of lesion would selectively affect these nerves/brainstem nuclei on both sides of the patient.

The most likely explanation for your observations is the rigidity associated with parkinsonism. The inability to initiate motion is one property of rigidity in which both agonist muscles (those that perform the intended movement) and their antagonists (those that resist the intended movement) are activated at the same time the patient wants to move (antagonist inhibition is disrupted in parkinsonism). Of course a MRI of his brain would help you to sort this out because certainly, apraxia after an undiagnosed stroke could cause motor planning problems (but the same stroke should not cause the bilateral cranial nerve lower motor neuron pattern observations.

If rigidity it might help to ask the patient whether he notes any improvement in the inability to initiate movement shortly after taking his Parkinson medications. Some patients (probably about 25%) notice a distinct “on” phase after medications in which they move much more easily for a short time. In those cases we ask the attending or neurologist to consider whether trying timing the medication to precede the intended activity (eating) by one-half hour or so is not contraindicated.

This article is an interesting as it relates to treatment of Parkinsons patients by using a motor pre-cue.

Johnson, A. M., Vernon, P. A., Almeida, Q. J., Grantier, L. L., & Jog, M. S. (2003). A role of the basal ganglia in movement: the effect of precues on discrete bi-directional movements in Parkinson's disease. Motor Control., 7, 71-81."

Ascites - CSD Student Contribution

Ascites

What is ascites? Ascites (AKA peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum, or abdominal dropsy) is an accumulation of fluid in the peritoneal cavity (space between the tissues lining the abdomen and abdominal organs). It is most commonly due to cirrhosis and severe liver disease, and can present other significant medical problems. It can be treated with medications (diuretics), paracentesis or other treatments directed at the particular cause. Mild ascites can be hard to notice, but severe ascites leads to abdominal distension. Fluid accumulation in the abdominal cavity can lead to additional fluid retention by the kidneys due to the stimulatory effects on blood pressure hormones (i.e. aldosterone). Ascites can also produce spontaneous bacterial peritonitis (SBP) due to the decreased antibacterial agents in the fluid. Patient complaints include progressive abdominal heaviness and pressure, and shortness of breath due to stress on the diaphragm. Other signs of ascites may be present due to its underlying etiology. For instance, in portal hypertension (perhaps due to cirrhosis or fibrosis of the liver) patients may also complain of leg swelling, bruising, gynecomastia, hematemesis, or mental changes due to encephalopathy. Those with ascites due to cancer (peritoneal carcinomatosis) may complain of chronic fatigue or weight loss. Those with ascites due to heart failure may also complain of shortness of breath as well as wheezing and exercise intolerance.

So what is ascites’ impact on speech? Ascites can affect respiratory support to due stress placed on the diaphragm which can lead many signs, such as: short breath groups, decreased loudness, reduced fluency (effect on prosody), inspiratory stridor, and difficulty coordinating breathing with swallowing due to reduced lung volumes on inhalation and expiration.

Encephalopathy may cause “mental” changes which can result in deficits in cognition, speech, and language, depending on which areas of the brain are affected.

Risks for Dehydration and/or Pneumonia

In the coming year the data from the Protocol 201 study, some of which was presented at the 2006 ASHA meeting, will be published. This study randomized aspirating Parkinson’s and dementia patients to either thin liquid using a chin-down posture, or thickened liquids (nectar or honey) for either three months follow up, or primary clinical end point (outcome of interest) of pneumonia, but hydration and nutritional parameters were also followed.



At the time of the ASHA meeting in 06, one interesting result presented was that patients in this study randomized to the “honey” thickened liquids intervention for managing aspiration of thin liquids, compared to the “nectar” thick and chin-down posture interventions, had significantly longer hospitalizations for pneumonia, than the pneumonia hospitalization durations for the other two interventions. I hope that the authors will clarify this with some data in their manuscripts and discuss this, as this “gel” discussion relates to the exact nature of the 201 finding: does aspirated thick liquid produce worse adverse outcomes than aspirated thin liquid.



The gel discussion aside, another important consideration is whether the patient drinks sufficient liquids once they are prescribed in their thick form. If we shift the risk from a potential respiratory adverse outcome (pneumonia) to a metabolic adverse outcome (inadequate hydration), there may be no net gain.

James L. Coyle

University of Pittsburgh

ASHA Convention 2007 Highlight

I wanted to draw your attention to Jim Coyle's presentation...-- "Ventilation, Respiration, & Pulmonary Diseases: Dysphagia-Related or Not?". It is session 1225 on Thursday from 8a-9a in room 257AB.

More on Polymyositis

Polymyositis

Polymyositis (PM) is found mostly in people over the age of 20 and affects more women than men. Muscle weakness usually happens over days, weeks or months. The weakness begins with muscles closest to and within the trunk of the body. Neck, hip, back and shoulder muscles are examples. Some patients also have weakness in muscles farther from the trunk, like hands and fingers. Some PM patients experience muscle pain, breathing problems, and trouble swallowing.

Researchers are finding that each case of PM is quite different from others. Sometimes, cases originally diagnosed as PM and not responding to treatment are later found to be inclusion-body myositis (IBM). Patients with certain types of PM may have one or more other autoimmune diseases.

Signs and symptoms

Signs

* Sudden or gradual weakness in the muscles
* Difficulty swallowing (dysphagia)
* Falling and difficulty getting up from a fall
* General feelings of tiredness


Symptoms

* Marked weakness in the muscles closest to the center of the body, like the forearms, thighs, hips, shoulders, neck and back
* Sometimes, weakness in the fingers and toes
* Thickening of the skin on the hands (mechanic’s hands)

Polymyositis: What Is It and How is it Related to Swallowing?

Look it up...

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?

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.

"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...

Swallowing Dysfunction and TEE

Authors Full NameKohr, Lisa M. Dargan, Margaret. Hague, Amy. Nelson, Suzanne P. Duffy, Elise. Backer, Carl L. Mavroudis, Constantine.
InstitutionDivision of Cardiovascular-Thoracic Surgery, Department of Speech and Language Pathology, Children's Memoiral Hospital,
TitleThe incidence of dysphagia in pediatric patients after open heart procedures with transesophageal echocardiography.
SourceAnnals of Thoracic Surgery. 76(5):1450-6, 2003 Nov.

AbstractBACKGROUND: Pediatric patients who undergo open heart operations may be at risk for the development of dysphagia because of interventions such as intubation and transesophageal echocardiography. Although the occurrence of dysphagia after cardiac surgical procedures in adults is reported to be 3% to 4%, the incidence in children and adolescents has not been documented. This study was undertaken to determine the incidence of and risk factors contributing to dysphagia in pediatric patients after open heart procedures. METHODS: Fifty patients were evaluated after open heart operations with transesophageal echocardiography between March 1, 1999, and September 30, 1999. The diagnosis of dysphagia was made by a speech pathologist using a clinical swallowing evaluation. Potential predictors examined included demographic variables, anatomical diagnosis, surgical procedure, size of the transesophageal echocardiographic probe in relation to body size, length of probe insertion time, preoperative patient acuity status, duration of intubation, and time until discharge. RESULTS: Dysphagia was found in 9 (18%) of the 50 patients. Risk factors identified were age of less than 3 years (odds ratio, 20.4; 95% confidence interval, 2.7 to 157; p = 0.002), intubation prior to operation (odds ratio, 17.7; 95% confidence interval, 9.4 to 210; p = 0.004), intubation for more than 7 days (odds ratio, 74.7; 95% confidence interval, 13.8 to 405; p = 0.001), and operation for left-sided obstructive lesions (odds ratio, 1.9; 95% confidence interval, 2.2 to 8.3; p = 0.038). The size of the transesophageal echocardiographic probe in relation to the weight of the patient was found to be predictive (p = 0.0001) of dysphagia. Vocal cord paralysis was noted in 4 (8%) of the 50 patients postoperatively. Adverse events related to aspiration occurred in 2 patients (4%). At discharge, nasogastric tube feedings were required in 6 patients (12%), and thickened feedings were recommended for 3 (6%) of the 50 patients. Resolution of dysphagia ranged from 13 to 150 days. CONCLUSIONS: Eighteen percent of patients had dysphagia after an open heart operation with transesophageal echocardiography. Age of less than 3 years, preoperative patient acuity status, longer intubation times, and operation for left-sided obstructions are risk factors for dysphagia in this cohort of pediatric patients. The size of the transesophageal echocardiography probe in relation to the patient's weight was predictive of dysphagia. Physicians should consider using the new mini-multiplane transesophageal echocardiographic probes in patients weighing less than 5.5 kg. Vigilance in monitoring for the signs of preoperative and postoperative dysphagia with prompt referral to a speech therapist can substantially reduce patient morbidity, length of hospital stay, and requirement of prolonged nasogastric tube use.

AuthorsRousou JA. Tighe DA. Garb JL. Krasner H. Engelman RM. Flack JE 3rd. Deaton DW.
Authors Full NameRousou, J A. Tighe, D A. Garb, J L. Krasner, H. Engelman, R M. Flack, J E 3rd. Deaton, D W.
InstitutionDepartment of Anesthesiology, Baystate Medical Center, Springfield, Massachusetts 01107, USA.
TitleRisk of dysphagia after transesophageal echocardiography during cardiac operations.
SourceAnnals of Thoracic Surgery. 69(2):486-9; discussion 489-90, 2000 Feb.
Local MessagesMUSC Library has journal title; click Library Holdings link for issues.
AbstractBACKGROUND: Dysphagia can be a significant complication following cardiac operations. This study evaluates its incidence and relationship to intraoperative transesophageal echocardiography (TEE) for specific indications versus known factors such as stroke or prolonged intubation. METHODS: Records of 838 consecutive cardiac surgical patients were reviewed, and categorized into those who received TEE for specific indications versus those who did not (nonTEE). Dysphagia was recorded when symptoms were confirmed by barium cineradiography. Multiple logistic regression identified significant factors causing dysphagia. RESULTS: TEE was significantly related to the development of postoperative dysphagia by multiple logistic regression (p <> CONCLUSIONS: TEE may be an independent risk factor for dysphagia following cardiac operations.

AuthorsHogue CW Jr. Lappas GD. Creswell LL. Ferguson TB Jr. Sample M. Pugh D. Balfe D. Cox JL. Lappas DG.
Authors Full NameHogue, C W Jr. Lappas, G D. Creswell, L L. Ferguson, T B Jr. Sample, M. Pugh, D. Balfe, D. Cox, J L. Lappas, D G.
InstitutionDepartment of Radiology, Washington University School of Medicine, St. Louis, Mo., USA.
TitleSwallowing dysfunction after cardiac operations. Associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography.
SourceJournal of Thoracic & Cardiovascular Surgery. 110(2):517-22, 1995 Aug.
Local MessagesMUSC Library has journal title; click Library Holdings link for issues.
AbstractThe frequency, importance to patient outcomes, and independent predictors of postoperative swallowing dysfunction documented by barium cineradiography were examined in 869 patients undergoing cardiac operations over a 12-month period. Swallowing dysfunction was diagnosed in 34 patients (4% incidence) and was associated with documented pulmonary aspiration in 90% of these patients, increased frequency of pneumonia (p < p =" 0.0002)," p =" 0.0001)," p =" 0.0001)." p =" 0.001)," class="bibrecord-highlight">transesophageal echocardiography (p = 0.003). Dysfunctional swallowing after cardiac operations, a serious complication significantly related to postoperative respiratory morbidity and extended length of hospitalization, is more common in older patients. An association between intraoperative use of transesophageal echocardiography and swallowing dysfunction was also observed in our patients.