Dysphagia in Parkinson's disease patients prior to deep brain stimulation: Is screening accurate?

BACKGROUND: Swallowing problems are common in Parkinson's Disease (PD) and aspiration pneumonia is the leading cause of death. Deep brain stimulation (DBS) surgery can successfully manage the motor symptoms of PD when pharmacological management begins to fail. Before DBS it is important to identify baseline dysfunction, but no consensus regarding swallowing screening exists. OBJECTIVES: This study was undertaken to: 1) identify the prevalence of dysphagia prior to DBS; and 2) determine if screening measures or other characteristics were predictive for reduced airway protection. METHODS: A standardized protocol was performed for 137 consecutive patients with idiopathic PD and no confounding medical conditions, including those referred for work-up of dysphagia (n = 57) and those prior to DBS (n = 80). Three validated screening measures were completed before videofluoroscopic evaluation. RESULTS: On videofluoroscopy, there were significant differences in reduced airway protection by group (dysphagia group: 44 %; pre-DBS group: 21 %). Aspiration also differed by group (dysphagia group: 18 %; pre-DBS group: 8 %) although not significantly. Although there were significant between-group differences, none of the screening measures was predictive of reduced airway protection or aspiration in the sample overall. Male gender, previous videofluoroscopic evaluation, history of pneumonia, and previous DBS surgery were associated with increased aspiration-risk. Age also showed a modest correlation. CONCLUSIONS: Dysphagia is not uncommon prior to DBS. No screening measure accurately predicted reduced airway protection on videofluoroscopy. Abnormal findings on clinical assessment prior to DBS, particularly in patients that are older, male, or have a history of pneumonia, may identify individuals requiring an objective dysphagia evaluation.

The impact of Lee Silverman Voice Treatment (LSVT LOUD®) on voice, communication, and participation: Findings from a prospective, longitudinal study.

BACKGROUND: Lee Silverman Voice Treatment (LSVT LOUD®), an intensive 4-week program of voice therapy, is regarded as the most well-researched, efficacious treatment for hypokinetic dysarthria in individuals with Parkinson's disease (PD). Although numerous studies have published acoustic and perceptual findings, there is comparatively little information about the impact of LSVT LOUD® on functional communication outcomes. METHODS: This prospective, longitudinal study investigated the impact of treatment on daily communication in 25 individuals with PD. Three validated communication measures (the Voice Handicap Index, the Communicative Effectiveness Scale, and the Communicative Participation Item Bank) were given before and after treatment and again 4-8 weeks and 3-6 months following treatment. Communication partners were also asked to rate communication effectiveness at all four timepoints. RESULTS: Significant improvements were found for all three self-reported scales which remained above baseline across all post-treatment timepoints. In addition, self-reported communicative effectiveness was significantly correlated with the assessments of communication partners. Particular benefits were reported for more complex communicative activities such as asking questions, giving detailed information, communicating in noisy situations, and speaking in groups. CONCLUSIONS: Overall, the findings suggested that LSVT LOUD® promotes an increased sense of personal control over the communication difficulties resulting from PD by decreasing voice handicap and improving communication effectiveness and communicative participation. For individuals with PD, LSVT LOUD® may reduce the risk of social isolation by improving communication and facilitating social participation. LEARNING OUTCOMES: As a result of this activity, the participant will be able to (1) describe the impact of PD on voice and communication, (2) discuss how these characteristics may be associated with more global measures of functional communication and particularly communicative participation, (3) explain which aspects of functional communication were affected by LSVT LOUD® as assessed by study participants and their communication partners.

Treatment Outcomes of Bilateral Medialization Thyroplasty for Presbylaryngis.

BACKGROUND: Presbylaryngis is a common cause of dysphonia in elderly patients. Type I thyroplasty serves to improve glottic closure and vocal quality by correcting bowing. Although unilateral and injection-based procedures are well-characterized in the treatment of broadly defined glottic insufficiency, there are insufficient outcomes data for bilateral medialization thyroplasty in the treatment of presbylaryngis. The aim of this study was to review the change in measures of vocal quality before and after bilateral medialization thyroplasty for presbylaryngis. STUDY DESIGN: This is a retrospective case series. METHODS: The records of 21 patients with presbylaryngis undergoing bilateral medialization thyroplasty between 2007 and 2014 were reviewed. Implant materials included silastic (n = 17) and hydroxyapatite (n = 4). Preoperative and postoperative comparison of vocal function was conducted using Voice Handicap Index, maximum phonation time, auditory-perceptual severity ratings, and blinded paired-comparison of Consensus Auditory-Perceptual Evaluation of Voice and Visual-perceptual stroboscopic ratings. Paired sample t tests were used to assess all outcome measures. RESULTS: Significant improvements were found in Voice Handicap Index scores (P < 0.007), maximum phonation time (P < 0.03), Consensus Auditory-Perceptual Evaluation of Voice (P < 0.04), and clinician rating of vocal quality (P < 0.0001). Blinded raters noted a significant improvement in audio (P < 0.05) and videostroboscopic (P < 0.003) samples after surgery. There were no operative complications observed, and median hospital stay was one night. CONCLUSIONS: Patients with presbylaryngis demonstrated significant improvement in both objective and subjective measures of vocal quality following bilateral medialization thyroplasty. These data suggest that medialization thyroplasty is a safe option that warrants consideration in the treatment of presbylaryngis.

Subjective and objective parameters of the adult female voice after cricotracheal resection and dilation.

OBJECTIVES: We compared the voice outcomes after cricotracheal resection (CTR) and airway dilation in adult women. METHODS: We performed long-term comprehensive voice assessments in 23 adult women treated for laryngotracheal stenosis, including acoustic and perceptual measurements of voice, videostroboscopy, the Voice Handicap Index, and an open-ended subjective questionnaire. RESULTS: Voice measures were abnormal in both groups. Objective pitch and loudness measurements were significantly more impaired after CTR than after dilation. Perceptual ratings of voice were worse after CTR than after dilation, particularly with regard to breathiness, pitch, and loudness. The CTR group was more likely to report a voice disorder, reported significantly more voice symptoms, and had higher voice handicap scores. Videostroboscopy was frequently abnormal in both groups, with more evidence of vocal hyperfunction after CTR. Self-ratings of breathing and swallowing were generally high in both groups, but voice satisfaction was rated lower after CTR. CONCLUSIONS: Voice was more significantly negatively impacted by CTR than by dilation. Surprisingly, many individuals in both groups reported improvements--a finding that possibly highlights the impact of laryngotracheal stenosis on airflow and vocal function before surgery. The importance of patient selection and preoperative counseling is emphasized, along with the potential need for voice therapy.