Lateral Medullary Stroke (LMS)

James Coyle writes:

a lateral medullary stroke (LMS). These strokes damage the important brainstem nuclei that mediate sensory and motor functions in the pharynx as the interconnections between them and other centers. Immediately prior to pharyngeal stage onset the UES resting pressure is seen to drop a little, due to inhibition of the vagal motor outflow to the sphincter. This tight, resting pressure keeps the UES tightly closed all of the time except when we swallow. In LMS the patient may have no inhibition of UES resting pressure, hence the h yolaryngeal musculature cannot overcome the intertia of the tight UES.


One clue is the side to which bolus flow is preferential. You said right. If this is true then the right pyriform sinus is more compliant than the left. Provided that you have trained him in airway protection maneuvers, head rotation might be worth assessing. I would expect that rotation away from the compliant side would facilitate flow to the more compliant side, but you cannot always predict this outcome based on lesion site knowledge because if an upper motor neuron lesion has produced denervation of the hypopharynx you will have a spastic paresis and less compliance, while a flaccid paralysis caused by a lower motor neuron (nucleus or nerve root) lesion will make the sinus more compliant. You will need to evaluate it provided it is safe to do so based on airway protection ability.

...Nearly 90-95% of the dysphagia seen in most patients with LMS resolves to a functional swallow or one that can be compensated with intervention.



James L. Coyle

University of Pittsburgh

Barium Standardization for MBS

Catriona M. Steele
Ph.D., M.H.Sc., S-LP(C), CCC-SLP, Reg. CASLPO writes:

Hi everyone!
I wanted to contribute to the discussion on barium standardization.

First let me start by saying that I believe the preferred option here is to use the Varibar products. These products have undergone rigorous testing.

However, if you are in a facility where Varibar is not yet available (which is true for all of us in Canada), then the next best approach is to standardize your barium recipes. I believe that we should be attempting to match the DENSITY of the Varibar products (acknowledging, of course that those products have the advantage of including various suspension agents and emulsifiers that are not part of the procedure I am going to describe below).

To make barium products of a specific DENSITY, you need a good digital scale as well as containers that specify volume (in ML). Density is always reported as a WEIGHT to VOLUME ratio. That means that for a specific VOLUME of liquid, you need to add a particular WEIGHT (in grams) of barium.

The particular amount of barium that you will add depends on the original barium product (is it a powder or already in liquid form?) and what density it is already determined to have. Liquid Polibar, for example, has a 100% weight to volume ratio in the bottle. Liquid Polibar Plus is slightly more dense (105% weight to volume). EZ-HD is intended to yield a 250% weight to volume suspension when you add the specified amount of water marked on the bottle.

So, in the absence of Varibar here in Canada, this is how I suggest that people attempt to standardize their home-made barium recipes (let me reiterate that I believe purchasing Varibar is the preferred option).

a) How to make ~1 cup (250 ml) of 40% w/v liquid barium suspension with Liquid Polibar(100% w/v base):

- Place an empty container on a digital balance and set the weight to 0 g.
- Pour in 100 g of Liquid Polibar.
- Add water until the volume reaches 250 ml.
- Shake well and leave to stand in a refrigerator.

b) How to make ~1 cup (250 ml) of 40% w/v liquid barium suspension with Liquid Polibar Plus (105% w/v base):

- Place an empty container on a digital balance and set the weight to 0 g.
- Pour in 95 g of Liquid Polibar Plus.
- Add water until the volume reaches 250 ml.
- Shake well and leave to stand in a refrigerator.

c) How to make 40% w/v barium products (any consistency) with E-Z-HD powder:

- Calculate the volume of liquid that you want to prepare (e.g. 250 ml)
- Determine the value of 40% of this volume (e.g., 250 X 0.4 = 100). Divide this value by 2.5 (e.g., 100/2.5 = 40).
- Using a digital balance, weigh out this value in grams of EZ-HD powder on a scale.
- Add this amount of powder to your liquid (e.g. 40 g of EZ-HD plus 250 ml of liquid).
- Shake or stir well with a whisk and store in a refrigerator.

Catriona M. Steele
Ph.D., M.H.Sc., S-LP(C), CCC-SLP, Reg. CASLPO

* Research Scientist, Toronto Rehabilitation Institute
* Corporate Practice Leader for Speech-Language Pathology and Audiology, Toronto Rehabilitation Institute
* CIHR New Investigator in Aging
* Assistant Professor, Department of Speech-Language Pathology, University of Toronto
* Coordinator-Elect, Special Interest Division 13 (Swallowing and Swallowing Disorders), American Speech-Language Hearing Association

Mailing Address:
550 University Avenue, #12030,
Toronto, ON, M5G 2A2
Telephone: 416-597-3422 X 7603
Fax: 416-597-7131
E-mail: steele.catriona@torontorehab.on.ca

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?