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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 17  |  Issue : 3  |  Page : 93-98

Videofluoroscopic study of swallowing disorders in patients with parkinsonism


1 Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences and Research Institute, Kochi, Kerala, India
2 Neurology, Amrita Institute of Medical Sciences and Research Institute, Kochi, Kerala, India
3 ENT Department, Amrita Institute of Medical Sciences and Research Institute, Kochi, Kerala, India

Date of Submission08-Jul-2021
Date of Acceptance03-Sep-2021
Date of Web Publication25-Nov-2021

Correspondence Address:
Dr. Unnikrishnan Menon
ENT Department, AIMS-Ponekkara PO, Kochi 682041, Kerala.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMJM.AMJM_32_21

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  Abstract 

Background: Dysphagia in Parkinsonism is often reported, and diagnosed, late. This can be a contributor to morbidity and mortality. Hence, a screening tool is essential as part of routine workup of these patients. The gold standard diagnostic modality for dysphagia is Videofluoroscopic Swallowing Study (VFSS). However, being an interventional imaging procedure, it cannot be made routine for every case. Aim: To study swallowing problems in patients with Parkinsonism using a screening questionnaire and to objectively observe the findings at VFSS in these patients. Materials and Methods: Fifteen patients (nine males and six females) attending the Parkinsonism clinic over a period of 1 year, and meeting the inclusion criteria, were included in the study. After standard neurological evaluation, they were administered our screening tool, the Amrita Dysphagia Screening Questionnaire (ADSQ). Next, they underwent VFSS. The scores and findings from these were documented, and the results were tabulated. Results: The average Hoehn and Yahr scale and ADSQ scores were 0.488 and 0.799, respectively. Mean age was 68.9 years. In VFSS, all the patients showed features of oropharyngeal swallowing disorders characteristic of Parkinsonism. These included features of bradykinesia such as tongue pumping, smaller tongue movements and piecemeal deglutition in the oral preparatory stage of swallowing, and reduced pharyngeal constriction, premature spillage, vallecular and pyriform sinuses residue, reduced hyoid movement, prolonged transit time, delayed laryngeal closure, aspiration/penetration, and repetitive or multiple swallow in the pharyngeal stage of swallowing. Conclusion: The present study has documented the objective findings of swallowing disorders, especially of the oral phase, in patients with Parkinsonism. This, along with our screening tool, must be considered essential in the management protocol for this debilitating neurological condition.

Keywords: Dysphagia, Parkinsonism, questionnaire, videofluoroscopy


How to cite this article:
Rajeev S, Radhakrishnan S, Vidhyadharan S, Menon U, Thankappan K, Iyer S. Videofluoroscopic study of swallowing disorders in patients with parkinsonism. Amrita J Med 2021;17:93-8

How to cite this URL:
Rajeev S, Radhakrishnan S, Vidhyadharan S, Menon U, Thankappan K, Iyer S. Videofluoroscopic study of swallowing disorders in patients with parkinsonism. Amrita J Med [serial online] 2021 [cited 2021 Dec 9];17:93-8. Available from: https://www.ajmonline.org.in/text.asp?2021/17/3/93/331116




  Introduction Top


Oropharyngeal dysphagia is one of the known features of Parkinsonism. It can lead to malnutrition, dehydration, reduced quality of life, aspiration pneumonia, and sepsis and as such, can contribute to morbidity and mortality of the condition.[1] Poor masticatory and oropharyngeal muscular control are thought to be the main causes for the dysphagia. This makes it difficult for the patient to chew and propel the bolus of food into the pharynx and oesophagus.[2] However, Parkinsonism-associated dysphagia is an underreported symptom. This has implications in terms of late diagnosis and effective reduction of the morbidity and mortality of the disease.

Swallowing mechanisms involve multiple areas of the brain such as cortex, basal ganglia, thalamus, brainstem, as well as cerebellum. The degenerative changes in these areas are more widespread and start earlier in Parkinson‚s plus syndromes as compared with the idiopathic Parkinson‚s disease (IPD).[3] Hence, the onset of dysphagia is usually earlier in the former. Yet, it may be missed on routine clinical evaluation, as it is often masked by compensatory mechanisms that occur at the cortical level..[4]

Modified Barium Swallow Study or Videofluoroscopic Swallowing Study (VFSS) and flexible endoscopic evaluation of swallowing are two routinely used investigations during objective assessment of dysphagia. However, in patients with Parkinson‚s disease (PD), these procedures can be justified only if there is suspicion of oropharyngeal dysphagia. This calls for a screening test, the easiest being a questionnaire.

The present study has utilized the Amrita Dysphagia Screening Questionnaire (ADSQ)—a screening tool developed and validated by the authors to assess subjective swallowing difficulties in patients with PD.[5] With this background information, we aimed to objectively study, and document, the swallowing problems in individuals with Parkinsonism, as observed by VFSS.


  Materials and Methods Top


Study setting and duration

This study was conducted over a period of 1 year, among patients attending the Movement Disorders Clinic in a tertiary care medical centre catering to a population of approximately 30 million in the state of Kerala in South India.

Patient selection and tools

There were 46 patients who attended the clinic in 1 year. They were subjected to disability scoring using the Hoehn and Yahr (H&Y) scale system. Those who scored 3 or less were subjected to dysphagia screening, using our validated tool ADSQ (Appendix 1). The patients were administered this tool in the Movement Disorder Clinic by a trained swallow pathologist and instructed to respond either by themselves or with the help of a nursing staff. The questionnaire consists of 11 questions, with each question having three responses with individual score given for each viz, never (0), sometimes (1), always (2), from which one response has to be selected by the patient. Those with a score of 2 or more were included in the study. Hence, among the 46 patients who answered the questionnaire, 15 patients qualified for the descriptive study.

Inclusion criteria

  • Patients with idiopathic and atypical PD attending PD clinic at the Department of Neurology, Amrita Institute of Medical Sciences


  • Dysphagia questionnaire score 2 or more


  • Exclusion criteria

  • Patients with swallowing questionnaire score less than 2


  • Patient with severe dysphagia


  • Patient with H&Y score 4 or greater


  • [Table 1] shows the demographics of patients selected for the study.
    Table 1: Demographics of the 15 patients selected for the study

    Click here to view


    Procedural details

    The above patients were subjected to VFSS for the imaging procedure.

    Instrument: Siemens Luminos Fusion

    View: lateral and anteroposterior

    For minimizing radiation exposure, the fluoroscopy unit was turned on intermittently every 15 to 30 seconds. The fluoroscopy unit was run continuously only when the swallowing function changed, usually signaled by spillover of material into the pyriform sinuses before initiation of the pharyngeal response. Overall, maximum radiation exposure was kept to a limit of 2 minutes. VFSS findings (images) were saved in the system. These were studied and documented by the swallowing pathologist, followed by analysis of certain parameters for the study purpose.

    There are many findings seen on VFSS, from the entry point of bolus per lips to its exit into the stomach. We chose eight parameters as being relevant to Parkinsonism. These are tabulated in [Table 2].
    Table 2: Eight VFSS parameters selected for the descriptive study

    Click here to view


    Of the above, three have numerical parameters, and hence can be analyzed quantitatively. These are

  • Number of swallows to clear one bolus


  • Oral transit time (OTT)


  • Bolus residue scale (BRS)


  • OTT is defined as the time (in seconds) from the onset of bolus movement in the mouth until the head of the bolus reaches the point where the lower rim of the mandible crosses the tongue base.

    BRS is (N. Rommel) an observational scale to determine the absence or presence of residue in the valleculae, pyriform sinuses, and/or the posterior pharyngeal wall.


      Results Top


    A total of 15 patients qualified for the study, of whom nine were males and six females. The mean age was 68.9 years. Out of 15, five had primary PD. According to the H&Y scale, all had mild-to-moderate Parkinsonism, the mean H&Y score being 2.67. The minimum ASDQ score was 3 and maximum was 6 with a mean of 3.93.

    Oral phase of swallow was found to be affected in all 15 patients. Various alterations in the oral preparatory stage and oral function were noted to varying degree. These included lingual tremor, increased oral residue, piecemeal deglutition, lingual pumping, preswallow spill, aspiration, and swallow hesitancy. However, all these findings do not have quantitative markers and so can only be marked as “present” in the documentation. In the pharyngeal stage of swallowing, reduced pharyngeal constriction, premature spillage, vallecular residue, reduced velopharyngeal pressure, residue in pyriform sinuses, reduced hyoid bone movement, decreased epiglottic rotation angle, prolonged transit time, delayed laryngeal closure, aspiration/penetration, and repetitive or multiple swallows were seen. Some, or all, of these were noted in all the 15 patients. We also noted that the muscles of pharynx which are responsible for bolus propulsion shows uncoordinated contraction during the phase of swallowing, resulting in pharyngeal accumulation of the bolus. Swallowing was also compromised by the lack of coordination between the glottis closure and the relaxation of the upper esophageal sphincter.

    Number of swallows to clear a bolus: normally, a single swallow is sufficient (score = 1). In this study, all 15 patients needed two or three swallows for clearance. There was no significant difference between the different types of Parkinsonism.

    OTT: the normal value is 1–2 seconds. It was found to be prolonged in all the patients, ranging from 3.04 to 6.37.

    BRS: normal swallowing does not lead to a bolus residue (score = 0). In this study, all 15 patients showed increased values, ranging from 2 to 6. [Table 3] and [Table 4] show the list of values.
    Table 3: Mean of OTT and BRS

    Click here to view
    Table 4: Numerical values of three parameters of all 15 patients

    Click here to view



      Discussion Top


    Swallowing is a complex process consisting of various pressure changes that successfully transport a bolus from the oral cavity to the oesophagus and into the stomach. This process can get disrupted in many neurological conditions, leading to a spectrum of swallowing disorders, termed dysphagia.

    Most of the patients with PD develop dysphagia during the course of their disease, leading to a compromised quality of life, due to disordered oral intake, malnutrition, and aspiration pneumonia, the latter being a major cause of death. Patients with PD develop oropharyngeal dysphagia approximately three times more than healthy elderly people. Although research suggests that one-third of people with Parkinson‚s (PwPs) have difficulty swallowing, medical observation suggests that the problem is even more widespread, as patients frequently do not report the problem. Studies have shown that dysphagia can be an early symptom in PD.[6] It becomes more prominent as the disease progresses in severity.

    Kalf et al.,[7] in a systematic meta-analysis review, observed that though subjective dysphagia occurred in one-third of community-dwelling patients with PD, the incidence of objectively measured dysphagia was much higher, with four out of five patients being affected. Affected patients rarely complain of dysphagia unless they are specifically asked about it in a clinical interview. The fact that dysphagia can remain subclinical or asymptomatic is plausible as patients gradually adapt to it as a consequence of the slow progression of PD. For example, they may swallow carefully, and with small bolus sizes, but dysphagia may come to light when such subjects are tested with a formal swallowing assessment. Patients with PD may be at increased risk for underestimation, because of cognitive deterioration or sensory problems, e.g., reduced cough reflex sensibility. Hence, early identification and management of dysphagia becomes a challenging task for the treating neurophysician to prevent aspiration and subsequently, an early mortality. So, there is a need for a screening tool, such as a questionnaire, which can be used in an outpatient setting so that the clinician can detect early dysphagia. Our validated ADSQ has proved useful in this regard. For the present study, we used the scores from this tool as an indication for the definitive diagnostic modality viz VFSS.

    VFSS is considered as the gold standard technique for the evaluation of dysphagia as it is the only diagnostic instrumental procedure in evaluation of dysphagia, which can identify all the stages of swallowing: oral, pharyngeal, and oesophageal stages and its abnormalities.[8] It allows clinicians to visualize the visuoperceptual and temporal parameters associated with swallowing disorders in an attempt to predict aspiration risk. Some of these parameters afford quantitative characterization. The goals of VFSS include assessment of efficacy and safety of deglutition, characterization of biomechanical deglutition impairment, and evaluation of treatment strategies.

    The videofluoroscopic changes in swallowing most frequently observed in Parkinson patients are alteration in preparation of the bolus, due to repeated tongue pumping movements, increased OTT, delayed triggering of the pharyngeal phase with difficulties in starting the automatic phase of deglutition, delayed onset of laryngeal elevation, reduced epiglottic tilting, and stasis in pyriform sinuses at the end of deglutition.[9],[10]

    Among these, oral-stage deficits are often, early indication of dysphagia in PD.[11] Limited excursion of the mandible contributes to prolonged duration for bolus preparation and chewing. Repetitive, backward and forward rocking motion of the tongue, termed “tongue pumping,” has been widely observed in Parkinson‚s, and is considered by some as pathognomic of the disease.[12] Liquid or saliva escaping anteriorly through the lips (i.e., drooling) also occurs fairly often in persons with Parkinson‚s.[13] All these findings were seen, and documented, in our set of patients. Qualitatively and quantitatively, the features were noted to be more in the atypical Parkinsonism, as compared with the idiopathic variety. However, this could not be statistically established due to the small number of cases. At the same time, it is important to note that all the cases that met the criteria for this study were restricted to PD patients living in the community. This implies that the prevalence is likely to be higher for the total population, including hospitalized and institutionalized PD patients.

    Some patients with Parkinson‚s also exhibit a delay in triggering the pharyngeal swallow, which, although mild, is associated with increased risk of aspiration.[12] This is because the pharyngeal residue can leak into the open airway once the pharyngeal swallow is complete. Decreased laryngeal elevation coupled with poor tongue base and pharyngeal wall motion may result in cricopharyngeal dysfunction where the bolus is unable to enter the oesophagus.[12] Laryngeal closure also may be incomplete during the pharyngeal stage of the swallow, and cough, which is an airway protective reflex, is frequently impaired in Parkinson‚s.[14] Impairment in cognition and upper extremity are some of the other factors that can worsen oropharyngeal dysphagia in advanced Parkinsonism. Impairments in oral and pharyngeal stages need to be closely observed because of the variability in the nature and severity of PD-related dysphagia. This yet again highlights the need for proactive screening for early detection of the significant problem in Parkinsonism.


      Conclusion Top


    The present study has documented the objective findings of swallowing disorders, especially of the oral phase, in patients with Parkinsonism.

    Our screening tool (ADSQ) is useful in an outpatient setting to identify patients with early dysphagia in patients with Parkinsonism. This is important even in mild-to-moderate disease.

    Videofluroscopic examination, based on above screening, helps to document abnormalities in Parkinsonism and to prepare early treatment strategies. Oral and oropharyngeal stages of swallowing are found to be affected more. These are noted to be more in atypical Parkinsonism compared with IPD in our descriptive study, though a statistical significance could not be analyzed due to the small sample size.


      Recommendation Top


    The early identification of dysphagia in Parkinsonism and need of VFSS should be considered essential throughout the diagnosis, planning of rehabilitation as it prevents the risk of aspiration, which is a major cause of death in individuals with this neurodegenerative condition.

    Acknowledgment

    Nil.

    Financial support and sponsorship

    Institutional support for the dissertation study based on which this article is written.

    Conflicts of interest

    There are no conflicts of interest.

    Author contributions

    SR: data acquisition and interpretation, literature review, and manuscript initial drafting.

    SKC: concept, data acquisition (patients), manuscript corrections, and final approval.

    SV: study design, literature review, and manuscript corrections.

    UKM: critical revision of manuscript and drafting the article.

    KT: data acquisition.

    SI: final approval.



     
      References Top

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    Wirth R, Dziewas R, Beck AM, Clavé P, Hamdy S, Heppner HJ, et al. Oropharyngeal dysphagia in older persons - from pathophysiology to adequate intervention: A review and summary of an international expert meeting. Clin Interv Aging 2016;11:189-208.  Back to cited text no. 1
        
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    Alexander GE. Biology of parkinson‚s disease: Pathogenesis and pathophysiology of a multisystem neurodegenerative disorder. Dialogues Clin Neurosci 2004;6:259-80.  Back to cited text no. 4
        
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    Radhakrishnan S, Menon UK, Sundaram KR. Usefulness of a modified questionnaire as a screening tool for swallowing disorders in Parkinson disease: A pilot study.Neurol India 2019;67:118-22.  Back to cited text no. 5
    [PUBMED]  [Full text]  
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    Ali GN, Wallace KL, Schwartz R, DeCarle DJ, Zagami AS, Cook IJ. Mechanisms of oral-pharyngeal dysphagia in patients with parkinson‚s disease. Gastroenterology 1996;110:383-92.  Back to cited text no. 6
        
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    Kalf JG, de Swart BJ, Bloem BR, Munneke M. Prevalence of oropharyngeal dysphagia in parkinson‚s disease: A meta-analysis. Parkinsonism Relat Disord 2012;18:311-5.  Back to cited text no. 7
        
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    Logemann JA. Evaluation and treatment of swallowing disorders. NSSLHA Journal 1984;12:38-50.  Back to cited text no. 12
        
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    Hartelius L, Svensson P. Speech and swallowing symptoms associated with parkinson‚s disease and multiple sclerosis: A survey. Folia Phoniatr Logop 1994;46:9-17.  Back to cited text no. 13
        
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    Ebihara S, Saito H, Kanda A, Nakajoh M, Takahashi H, Arai H, et al. Impaired efficacy of cough in patients with parkinson disease. Chest 2003;124:1009-15.  Back to cited text no. 14
        



     
     
        Tables

      [Table 1], [Table 2], [Table 3], [Table 4]



     

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