Comments on Selected Recent Dysphagia Literature

David W. Buchholz, MD and Stefanie Neumann MA

Response of Parkinsonian Swallowing Dysfunction toDopaminergic StimulationHunter PC, Crameri J, Austin S, Woodward MC,Hughes AJJ Neurol Neurosurg Psychiatry 63:579–583, 1997

Fifteen patients with idiopathic Parkinson’s disease andsymptomatic dysphagia were studied. All had motorfluctuations in response to long-term levodopa therapy.On 2 separate days, after overnight withdrawal of allantiparkinsonian medication, videofluorographic swal-lowing studies were performed before and after levodopaand apomorphine.

In response to dopaminergic stimulation, ‘‘littleconsistent improvement occurred.’’ Hunter et al. report,‘‘An improvement in the oral preparatory phase time wasseen with levodopa in the group as a whole, and afterapomorphine in the subgroup of patients with the mostabnormal results, but only with some bolus consisten-cies.’’ The authors speculate that ‘‘Parkinsonian swal-lowing dysfunction is not solely related to nigrostriataldopamine deficiency and may be due to additional non-dopamine-related disturbance of the central pattern gen-erator for swallowing in the pedunculopontine nucleus orrelated structures in the medulla.’’

CommentsThe mixed but generally negative findings of Hunter etal. regarding response of parkinsonian swallowing dys-function to dopaminergic stimulation are generally simi-lar to those previously described [1–5].

References

1. Bushmann M, Dobmeyer SM, Leeker L, Perlmutter JS: Swal-lowing abnormalities and their response to treatment in Parkin-son’s disease.Neurology 39:1309–1314, 1989

2. Calne DB, Shaw DG, Spiers ASD, Stern GM: Swallowing inparkinsonism.Br J Radiol 43:456–457, 1970

3. Tison F, Wiart L, Guatterie N, Fouillet N, Lozano V, Henry P,Barat M: Effects of central dopaminergic stimulation by apo-

morphine on swallowing disorders in Parkinson’s disease.MoveDisord 11:729–732, 1996

4. Paulson GR, Tafrate RH: Some minor aspects of parkinsonismespecially pulmonary function.Neurology 20:14–17, 1970

5. Fonda D, Schwarz J: Parkinsonian medication one hour beforemeals improves symptomatic swallowing: a case study.Dyspha-gia 10:165–166, 1995

Predictive Value of Clinical Indices in Detecting As-piration in Patients with Neurological DisordersMari F, Matei M, Ceravolo MG, Pisani A, Provinciali LJ Neurol Neurosurg Psychiatry 63:456–460, 1997

Ninety-three consecutive patients with neurological dis-eases with risk of swallowing dysfunction were studiedby means of (1) clinical assessment using a 25-itemform, (2) 3-oz water swallow test [1], and (3) videofluo-roscopy. The predictive value of the clinical assessmentand 3-oz water swallow test was compared with video-fluoroscopic documentation of aspiration as the goldstandard.

Mari et al. found that ‘‘non-specific complaintsof dysphagia showed a very poor predictive value,whereas the symptom ‘cough on swallowing’ proved tobe the most reliable in predicting the risk of aspira-tion. . . . Thestandardized 3-oz test had a higher predic-tive potential than the clinical signs, but had low sensi-tivity . . . . Incases where the clinical tests failed to detectany impairment, videofluoroscopy documented only alow risk (20%) for mild aspiration.’’

Mari et al. conclude, ‘‘The association of the 3-oztest with the clinical index ‘cough on swallowing’ pro-vides a useful screening tool, the cost:benefit ratio ofwhich seems competitive with videofluoroscopy inevaluating risk of aspiration.’’

CommentsThis is further evidence that bedside evaluation is rea-sonably reliable in identifying patients with aspirationdetectable by videofluoroscopy. One might ask whetheror not the false negative error rate of bedside evaluationis acceptable. A better question would be whether or not

Dysphagia 13:235–236 (1998)

© Springer-Verlag New York Inc. 1998

it makes a difference in patient outcomes to ascertainaspiration by means of either bedside evaluation or vid-eofluoroscopy. In other words, does awareness of aspi-ration enable us to implement intervention that is trulyeffective in reducing complications of aspiration?

Reference

1. DePippo K, Holas M, Reding M: Validation of 3-oz water swal-low test for aspiration following stroke.Arch Neurol 42:1259–1261, 1992

Aspiration in Patients with Acute StrokeDaniels SK, Brailey K, Priestly DH, Herrington LR,Weisberg LA, Foundas ALArch Phys Med Rehab 79:14–19, 1998

Fifty-five consecutive stroke patients were evaluatedwithin 5 days of acute stroke. Evaluation included clini-cal swallowing and oromotor examinations and video-fluoroscopic swallowing studies (VSS).

Daniels et al. found that 21 of 55 patients (38%)aspirated. Of those who aspirated, one third did soovertly and two thirds did so silently (i.e., detectable byvideofluoroscopy only). The authors report that ‘‘dys-phonia, dysarthria, abnormal gag reflex, abnormal voli-tional cough, cough after swallow, and voice change af-ter swallow were significantly related to aspiration andwere predictors of the subset of patients with silent as-piration.’’ Abnormal volitional cough and cough withswallow, in conjunction, predicted aspiration with 78%accuracy.

Of the 50 surviving patients, 94% returned to oralintake. The rate of resolution of dysphagia was identical(83%) among patients with overt aspiration (5 of 6 suchpatients) and those with silent aspiration (10 of 12). Oneof the 55 acute-stroke patients developed aspirationpneumonia during hospitalization, and this patient hadovert dysphagia.

Daniels et al. conclude, ‘‘These data suggest thata detailed and accurate clinical assessment is essentialfor the early identification of acute stroke patients at riskof aspiration toensure proper management,to preventensuing complications,and todetermine which patientsmay need VSS’’ (emphasis added).

CommentsThe well-done study speaks for itself except that we mustspeak up, at the risk of repeating ourselves, to point outthat it is unsound to draw any conclusions about ensuring

proper management, preventing ensuing complications,or needing VSS, based on the findings of this or anyother study of bedside evaluation of dysphagia. Avail-able data do not justify the position that we are able toimprove outcomes by means of our evaluation and treat-ment of dysphagia, yet this position pervades the litera-ture as a matter of faith.

Laryngeal Framework Surgery for the Managementof Aspiration in High Vagal LesionsPou AM, Carrau RL, Eibling DE, Murry TAm J Otolaryngol 19:1–7, 1998

Pou et al. performed a retrospective chart review of pa-tients presenting with ‘‘high vagal lesions’’ who weretreated with laryngeal framework surgery within a 4-yearperiod. Thirty-five patients were analyzed for the effec-tiveness of laryngeal framework surgery, including me-dialization thyroplasty (MT), with or without arytenoidadduction (AA), on preventing aspiration, improvingdiet, and aiding in the subsequent decannulation of theseindividuals.

The majority of patients had neurological deficitsfollowing surgery for skull base tumors, but there wereother underlying disorders including stroke and brain tu-mors. Among the 35 patients, there were 40 MTs and 19AAs as well as 23 cricopharyngeal myotomies. The au-thors report, ‘‘Ninety-four percent of patients who expe-rienced aspiration improved, and 79% who had requiredtracheotomy were decannulated. Ninety percent of pa-tients were noted to have subjective improvement invoice postoperatively.’’ They conclude, ‘‘Laryngealframework surgery improves airway, deglutition, andvoice in individuals suffering from high vagal lesions,and facilitates the rehabilitation of these patients.’’

CommentsThe term ‘‘high vagal lesions’’ is best avoided, becauseit fails to accurately reflect the varied underlying neuro-logical dysfunctions in a group of patients as diverse asthose reported in this study. More importantly, this studyhas shortcomings in terms of methodology and reportingthat make it difficult for us to draw clear conclusions asto the role of laryngeal framework surgery in managingaspiration and preventing its complications. We hopethat future studies will better clarify the potential forlaryngeal framework surgery to benefit, in terms ofmeaningful outcome measures, defined subgroups of ourpatients who are unresponsive to more conservative ap-proaches.

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