Oral function test for monitoring suction and swallowing in the neurologic patient

Disturbances in swallowing are common in neurologic disease but difficult to evaluate in the clinical setting. Fundamental variables such as bolus volume, swallow capacity (volume ingested over time), and the relation between ingestion and time for important events in oral and pharyngeal swallowing have not been sufficiently studied. We therefore employed a composite method for monitoring oral and pharyngeal swallowing function: the test of Repetitive Oral Suction Swallow (the ROSS test). The technical details are described as well as preliminary results from a pilot study of 20 healthy subjects and 5 patients with neurologic swallowing impairment. The correlation with respect to time sequences for major events in bolus ingestion and oral processing as monitored by the ROSS test and by videoradiography is explained. With this simple and rapid bedside test, the immediate and long-time result of therapeutic interventions in dysphagic patients may be monitored

Quantitative assessment of oral and pharyngeal function in Parkinson's disease

Oral and pharyngeal dysfunction is common in Parkinson's disease. To reveal the frequency of swallowing dysfunction and correlate swallowing dysfunction with locomotor disturbances, we studied 75 patients with Parkinson's disease staged I-IV according to the Hoehn and Yahr score. We assessed oral and pharyngeal swallow during optimal medication by a quantitative test of swallowing (the ROSS test) measuring the suction pressure, bolus volume, swallowing capacity, and time for important events in the swallowing cycle. We found abnormal results in 7/12 patients (58%) in stage 1 of the Hoehn and Yahr score, in 13/14 patients (93%) in stage 2, in 29/32 patients (91%) in stage 3, and in 16/17 patients (94%) in stage 4. Abnormal test results in stages, 1, 2, and 3 were seldom related to swallowing difficulties noticed by the patients. In advanced disease (Hoehn and Yahr stage 4), the abnormal results were often considerable, with swallowing difficulties obvious to the patient. Two of 17 patients coughed during or immediately after the test and 3/ 17 patients were unable to complete the test. The degree of swallowing disturbance increased during stress (forced, repetitive swallow). The Hoehn and Yahr score and the results in the ROSS test did not correlate, indicating that swallowing disturbances are due to nondopaminergic degeneration. Silent swallowing impairment may interfere with the nutrition and quality of life in Parkinson's disease, thus it is of interest to monitor this in clinical practice

Swallowing in hereditary sensory ataxia

The oral, pharyngeal, and esophageal stages of swallowing were evaluated in 8 patients with recessively or dominantly inherited pure sensory ataxia. Six patients had swallowing difficulties: solid bolus obstruction, coughs during eating, and choking episodes. One patient had chronic bronchitis and another had recurrent pneumonia. The patients underwent a biphasic radiological barium swallow, including videofluoroscopy. No patient had a completely normal swallow. All had normal oral function, whereas pharyngeal function was abnormal in 6 patients. Esophageal function was abnormal in 6 patients. The swallowing dysfunction did not correlate with the severity of motor or sensory dysfunction in the limbs, nor with age or duration of ataxia. Our study shows that swallowing dysfunction is common in hereditary sensory ataxia. This dysfunction is likely to be due to involvement of the nucleus of the solitary tract in the brainstem. Despite some of the patients having suffered from choking episodes and others from bronchopulmonary complications, they did not spontaneously admit dysphagia. Swallowing should be evaluated thoroughly in patients with hereditary sensory ataxia since dysphagia in these patients might bring serious and potentially fatal complications

Dysphagia in stroke: a prospective study of quantitative aspects of swallowing in dysphagic patients

This is a prospective study of 100 consecutive stroke patients. Within 24 h after stroke onset they were asked specifically about swallowing complaints and subjected to a clinical examination including neurologic examination, Mini-Mental test, and Barthel score. Dysphagic patients were examined with the repetitive oral suction swallow test (the ROSS test) for quantitative evaluation of oral and pharyngeal function at 24 h, after 1 week, and after 1 month. At 6 months, the patients were interviewed about persistent dysphagia. Seventy-two patients could respond reliably at 24 h after the stroke onset and 14 of these complained of dysphagia. Non-evaluable patients were either unconscious, aphasic, or demented. The presence of dysphagia was not influenced by age or other risk factors for stroke. Facial paresis, but no other clinical findings, were associated with dysphagia. Dysphagia 24 h after stroke increased the risk of pneumonia but did not influence the length of hospital stay, the manner of discharge from hospital, or the mortality. The initial ROSS test, during which the seated patient ingests water through a straw, was abnormal in all dysphagic stroke patients. One-third of the patients were unable to perform the test completely. Above all, dysfunction was disclosed during forced, repetitive swallow. All phases of the ingestion cycle were prolonged whereas the suction pressures, bolus volumes, and swallowing capacities were low. Abnormalities of quantitative swallowing variables decreased with time whereas the prevalences of swallowing incoordination and abnormal feeding-respiratory pattern became more frequent. After 6 months, 7 patients had persistent dysphagia. Five of these were initially non-evaluable because of unconsciousness, aphasia, or dementia

Assessment of respiration during video fluoroscopy of dysphagic patients

RATIONALE AND OBJECTIVES: The authors evaluated the coordination of swallowing and respiration in dysphagic patients. MATERIALS AND METHODS: Video fluoroscopy and respirometry were performed simultaneously during 98 swallows in 33 patients (18 women, 15 men) with a median age of 70 years (interquartile range, 52-78 years). Pharyngeal transit time, deglutition apnea, and the ratio between the two (swallowing safety index) were calculated. Presence of a misdirected swallow (aspiration or penetration) was indicated. RESULTS: Pharyngeal transit time was not associated with deglutition apnea. Misdirected swallow was associated with a slightly prolonged pharyngeal transit time, a slightly shorter deglutition apnea, and a significantly lower swallowing safety index (1.8 [1.0-4.2] vs 4.5 [2.4-6.7]; P < .001) compared with normally directed swallow. The association between misdirected swallow and lower swallowing safety index was independent of pharyngeal transit time. CONCLUSION: Assessment of respiration is important in the evaluation of dysphagia. Aspiration, especially in elderly dysphagic patients, may be a consequence of primarily disturbed respiration. A low swallowing safety index may indicate risk of misdirected swallow

Quantitative aspects of swallowing in an elderly nondysphagic population

The prevalence of swallowing impairment increases with age and is a major health care problem in the elderly. It has been assumed that age-related changes in nerves and muscles hamper muscle strength and coordination of swallowing. However, it is unclear what impairment is related to primary aging and what is the consequence of diseases prevalent in the elderly (secondary aging). In order to quantify swallowing in nondysphagic elderly we used the noninvasive ROSS (Repetitive Oral Suction Swallow) test. A total of 53 individuals aged 76 +/- 5 years (mean +/- SD) were examined. We found that the nondysphagic elderly demonstrated significant differences compared with young individuals in 10 of 17 measured variables, i.e., decreased peak suction pressure, increased frequency of multiple swallows after one ingestion, increased frequency of polyphasic laryngeal movements, increased frequency of inspiration after swallowing, and increased frequency of coughing during or after swallowing. Therefore, primary aging mainly seems to influence coordination of swallowing, but oral and pharyngeal swallow per se seem to be unaffected

Quantitative assessment of swallowing in healthy adults

Swallowing has hitherto been evaluated during physical examination, radiologic barium studies, manometry, and cervical auscultation. Radiography principally demonstrates qualitative aspects of oral and pharyngeal function, whereas quantitative aspects have primarily been documented by manometry. To evaluate swallowing quantitatively, without using invasive methods or radiation, we have applied a combined test of water drinking, i.e., the Repetitive Oral Suction Swallow test (ROSS). The test provides reliable measurements of suction pressure, bolus volume, timing of important events in oral and pharyngeal swallow, and respiration. The test is described and results from 292 healthy, non-dysphagic subjects are presented. We found a mean bolus volume of 25.6 +/- 8.5 ml during single swallow and 21.1 +/- 8.2 ml during stress (forced, repetitive swallow). During forced, repetitive swallow, the bolus volume was more strongly associated with suction time (r2 = 0.55) than with peak suction pressure (r2 = 0.04), indicating that suction time is more important than suction pressure in determining the bolus volume. The oral-pharyngeal transit time decreased: single swallow 0.56 +/- 0.36 sec, forced repetitive swallow 0.23 +/- 0.11 sec, as did the coefficient of variation (48% and 64%, respectively) indicating a more automatic neural process for pharyngeal function in forced, repetitive swallow. The postswallow respiration started with inspiration in 10% of studied individuals, but did not correlate with deviations in other variables in the test. Thus, postswallow inspiration must be considered as normal. The ROSS test offers a rapid and easy quantitative assessment of swallowing

Visually evoked slow eye movements, visual-vestibular interaction, and infratentorial lesions

The maximum velocity gain of smooth pursuit and optokinetic, vestibular, and optovestibular slow phases was examined in 15 patients with pontine, 10 with medullary, 10 with cerebellar, and 5 with combined cerebello-brain stem disorders. Marked dissociations were observed between smooth pursuit and optokinetic slow phases, especially in medullary disease. A cerebellar deficit enhanced slow phase velocity gain during rotation in darkness, whereas the corresponding gain during rotation in light was normal