This is an interesting German study of dysphagia (swallowing problems) in PSP.
“Dysphagia is…a common feature in PSP occurring in up to 80% of patients. In comparison to Parkinson’s disease (PD), median dysphagia latency and survival time after onset of dysphagia are significantly shorter in PSP. Dysphagia may result in aspiration and subsequent pneumonia, which is the leading cause of death in both disorders. Other complications of swallowing dysfunction are discomfort while eating, difficulties in taking oral medications, weight loss, and dehydratation. Furthermore, swallowing disturbance is associated with increased anxiety and depression and significantly affects the quality of life in parkinsonian syndromes. Therefore, early detection and timely interventions are mandatory to prevent the serious consequences of dysphagia.”
In this study, the FEES test was used: fiberoptic endoscopic evaluation of swallowing. (The R in FEES(R) is “registered trademark.”) The FEES test includes a flexible fiberoptic endoscope in put down the nose, providing a view of the swallowing structures.
Eighteen PSP patients and 15 advanced stage PD (Parkinson’s Disease) patients were given this test. Seven of the PSP patients were tested after they had been given levodopa (Sinemet is a brand name). “Two PSP patients showed relevant improvement of swallowing function after L-dopa challenge.” One patient was able to return to normal food and the other patient had a nasogastric tube removed.
“Aspiration events with at least one food consistency occurred in nearly 30% of PSP patients.”
“In early PSP patients, swallowing dysfunction was solely characterized by liquid leakage with the risk of predeglutitive aspiration during the oral phase of swallowing. … More than half of these patients did not recognize their disability. These observations may suggest that liquid leakage resulting from a disturbed oral swallowing phase is another early and under diagnosed ancillary clinical attribute in PSP differentiating this condition from PD.”
“Endoscopic dysphagia severity in PSP correlated positively with disease duration, clinical disability, and cognitive impairment. … There were no significant differences between the PSP and PD patients.”
This finding was interesting: “No correlation was found with dysarthria severity.” I would’ve thought that dysarthria severity and dysphagia severity were highly correlated.
And this finding was also interesting: “Significant pharyngeal saliva pooling was observed in 4 PSP patients.” It has been shown that “pharyngeal saliva pooling strongly predicts severe dysphagia and substantially increases the risk for the development of aspiration pneumonia.”
“Chin tuck-maneuver, hard swallow, and modification of food consistency were identified as the most effective therapeutic interventions.” Two examples of food consistency modification are restriction to pureed food or restriction to soft solid food. “[In] certain PSP patients with delayed swallowing reflex [a] hard swallow may not be an appropriate maneuver, because it potentially further increases the duration of pharyngeal response.”
The researchers had something to say about PEG feeding tubes. “Although several severely affected PSP patients participated in our study, only two subjects required percutaneous endoscopic gastrostomy. In our opinion, a percutaneous endoscopic gastrostomy should be considered in PSP patients when there is endoscopic or videofluoroscopic evidence that all food consistencies are aspirated without any objective improvement by L-dopa challenge and/or nonpharmacological therapeutic interventions.”
Robin
Movement Disorders. 2010 Mar 29. [Epub ahead of print]
Endoscopic characteristics and levodopa responsiveness of swallowing function in progressive supranuclear palsy.
Warnecke T, Oelenberg S, Teismann I, Hamacher C, Lohmann H, Ringelstein EB, Dziewas R.
Department of Neurology, University Hospital of Münster, Münster, Germany.
Abstract
Dysphagia is a frequent and early symptom in progressive supranuclear palsy (PSP) predisposing patients to aspiration pneumonia. Fiberoptic endoscopic evaluation of swallowing (FEES(R)) has emerged as a valuable apparative tool for objective evaluation of neurogenic dysphagia. This is the first study using FEES(R) to investigate the nature of swallowing impairment in PSP.
Eighteen consecutive PSP patients (mean age 69.7 +/- 9.0 years) were included. The salient findings of FEES(R) in PSP patients were compared with those of 15 patients with Parkinson’s disease (PD). In 7 PSP patients, a standardized FEES(R) protocol was performed to explore levodopa (L-dopa) responsiveness of dysphagia.
Most frequent abnormalities detected by FEES(R) were bolus leakage, delayed swallowing reflex, and residues in valleculae and piriformes. Aspiration events with at least one food consistency occurred in nearly 30% of PSP patients. Significant pharyngeal saliva pooling was observed in 4 PSP patients.
We found no difference of salient endoscopic findings between PSP and PD patients.
Endoscopic dysphagia severity in PSP correlated positively with disease duration, clinical disability, and cognitive impairment. No correlation was found with dysarthria severity. In early PSP patients, swallowing dysfunction was solely characterized by liquid leakage with the risk of predeglutitive aspiration during the oral phase of swallowing.
Two PSP patients showed relevant improvement of swallowing function after L-dopa challenge.
Chin tuck-maneuver, hard swallow, and modification of food consistency were identified as the most effective therapeutic interventions.
In conclusion, FEES(R) assessment can deliver important findings for the diagnosis and refined therapy of dysphagia in PSP patients.
(c) 2010 Movement Disorder Society.
PubMed ID#: 20629130 (see pubmed.gov for this abstract only)