Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4523_Библиотеки_им_академика_М_И_Перельмана

Therapeutic techniques will evolve over t ime dependent on the progress and needs of the patient.

In addition to direct therapy, a patient can utilize computer­ized home training to support development of auditory skills.

Vertical phase difference (VPD) and mucosal wave were absent on the right vocal fold at site of grooving, and reduced on the left vocal fold at site of lesion.

Hourglass phonatory closure pattern at all pitches.

the initial evaluation, HG reported complete resolution of vocal pain, no observable vocal effor t, and increased/functional vocal stamina. He also noted that voice quality, while still breathy from time to time, was no longer unstable or unpredictable, and was felt to be consistently smoother and less dysphonic. Perceptual assessment by both the SLP and MD revealed improved voice quality, now with minimal breathiness, inter­mittent strain and roughness, and minimal thyrohyoid and jaw tension. Laryngoscopic evaluation revealed persistent right vocal fold scar and left vocal fold cyst that was reduced in size compared to initial evaluation (▶ Fig. 67.2). Stroboscopic evalu­ation revealed improved VPD and mucosal wave and complete closure at all pitches elicited (▶ Fig. 67.2).

Aspiration pneumonia is the leading cause of death in Parkinson’s disease (PD) and much of this pulmonary sequelae can likely be attributed to the concomitant presence of swal­lowing (dysphagia) and cough (dystussia) disturbances, which are often present in PD. evaluate and manage behaviors across the continuum of airway protection (from cough to swallowing) for improved long-term health outcomes.

GB was a 69-year-old man who presented with Hoehn and Yahr stage III PD with symptom onset 8 years prior. His medical history was also significant for right unilateral subthalamic nucleus (STN) deep brain stimulation (DBS) surgery followed by left globus pallidus interna (GPi) DBS surgery 3 years later. Of note, DBS has evolved as the management option of choice for persons with PD. The two subcortical structures most com­monly targeted during surgery for the treatment of PD are the STN and GPi. Although STN and GPi DBS are generally consid­ered safe and effective for the treatment of people with PD, less is known about the impact of DBS on airway protection. Recent work suggests that STN DBS may result in adverse effects to swallowing function, which are not observed with GPi DBS.

GB was referred to our outpatient clinic due to a progressive swallowing disturbance adversely affect ing oral intake and quality of life. GB and his wife reported that over the past year, he developed significant coughing with meals, particularly when drinking liquids. He also reported that it was taking him much longer to eat. His wife also noticed that he was drool­ing more often and coughing throughout the day even in the absence of food or liquid. They also reported marked speech dif­ficulties. GB’s wife was particularly worried about his reduced loudness in conversation. GB and his wife reported that his speech function worsened with DBS, but were most concerned about his swallowing dysfunction. Prior to being seen in our clinic, GB had undergone several swallowing evaluations and subsequent treatment at other facilities. He reported that his swallowing therapy consisted of oral motor exercises, the Shaker exercise, and effortful swallow. Additionally, a neurolo­gist recommended he employ a chin tuck when drinking thin liquids. GB had no history of aspiration pneumonia or recent weight loss. He was quite active, participating in weekly exer­cise classes, cognitive therapy, and a PD support group. He and his wife were very motivated to address these swallowing concerns, but were adamantly opposed to any form of enteral feeding.

Videofluoroscopic evaluation of swallowing (VFES; ▶ Video 68.1) was performed. This examination revealed aspiration of sequen­tial thin liquid boluses and consistent penetration to the level of the vocal folds with sequential presentation of nectar-thick liquids. GB did not cough in response to the aspiration and/or penetration. GB coughed when cued, but the cough was ineffec­tive in clearing the aspirate/penetrant material from the airway. His swallowing was also characterized by reduced extent and duration of pharyngoesophageal segment opening, moderate pharyngeal residue, pooling in the valleculae with pudding and solid boluses, and reduced pharyngeal contraction. Oral transit time was increased, especially for solid and pudding boluses. A chin tuck was trialed with thin liquids, given that it had been recommended by a prior neurologist; however, persistent aspira­tion was noted evenwith the chin tuck.