Cinefluorographic evaluation of swallowing in patients with involuntary movements

Obstructive asphyxia: a cause of excess mortality in psychiatric patients

The purpose of this study was to determine the number of deaths which were caused by choking in a 10 year period in the Irish psychiatric in-patient population and the factors associated with such deaths.

Electrophysiological evaluation of pharyngeal phase of swallowing in patients with Parkinson's disease

We studied the various physiological aspects of oropharyngeal swallowing in Parkinson's disease (PD). Fifty-eight patients with PD were investigated by clinical and electrophysiological methods that measured the oropharyngeal phase of swallowing. All patients except 1 had mild to moderate degree of disability score. Dysphagia was demonstrated in 53% of all patients in whom the test of dysphagia limit was abnormal. All PD patients with or without dysphagia displayed the following abnormalities: (1) the triggering of the swallowing reflex was prolonged probably due to inadequate bolus control in the mouth and tongue and/or a specific delay in the execution of the swallowing reflex; (2) the duration of the pharyngeal reflex time was extremely prolonged due to slowness of the sequential muscle movements, especially those of the suprahyoid-submental muscles; (3) cricopharyngeal muscle of the upper oesophageal sphincter was found to be electrophysiologically normal; and (4) the electrophysiological phenomena in PD patients could not be strongly correlated with the degree of the disability and clinical score of the PD. It was concluded that various motor disorders of PD have considerable influence on oropharyngeal swallowing: hypokinesia, reduced rate of spontaneous swallowing, and the slowness of segmented but coordinated sequential movements rather than any abnormalities in the central pattern generator of the bulbar center. Some compensatory mechanisms in the course of PD may explain the benign nature of swallowing disorder until the terminal stage of the disease. Similarly, the swallowing problems of PD are not only related with the dopamine deficiency; some other nondopaminergic mechanisms may also be involved.

Prepharyngeal dysphagia in Parkinson's disease

Dysphagia in patients with Parkinson's disease (PD) is most often attributed to pharyngeoesophageal motor abnormalities. In our study of patients with idiopathic PD, attention was focused on prepharyngeal symptoms and motor functions. Using the Hoehn and Yahr disease severity scale, patients were grouped into those with mild/moderate disease [subgroup I (n = 38)] and those with advanced disease [subgroup II (n = 34)]. Dysphagia symptoms were present in 82% of all patients, but subgroup I patients voiced significantly more complaints. Conversely, many prepharyngeal abnormalities of ingestion, including jaw rigidity, impaired head and neck posture during meals, upper extremity dysmotility, impulsive feeding behavior, impaired amount regulation, and lingual transfer movements were statistically more frequent in subgroup II patients. Impaired mastication and oral preparatory lingual movements were the most common aberrations observed during dynamic videofluoroscopy (48/71), with most patients being concordant for both. The motor disturbances of ingestion reported herein reflect the disintegration of volitional and automatic movements caused by PD-related akinesia, bradykinesia, and rigidity.

Tardive dyskinesia presenting as severe dysphagia

A case of tardive dyskinesia presenting with severe dysphagia as the predominant feature is described. Diagnosis was delayed because clinically apparent orofacial dyskinetic movements were minimal. The symptoms resolved following the cessation of neuroleptic medication.

Dysphagia in psychiatric patients: clinical and videofluoroscopic study

Deaths due to airway obstruction are more common in psychiatric inpatients than in the normal population. A dysphagia program was started in a 400 bed Massachusetts psychiatric hospital after 4 patients in 1 year died from asphyxia. In the year after the program was started, there were no deaths; however, 28 patients experienced 32 choking incidents. The 28 patients received clinical evaluations by speech pathologists, neurologists, psychiatrists, and internists. Of the incidents, 55% required use of the Heimlich maneuver to open the airway. Choking incidents could be classified into five types based on results of clinical examination: bradykinetic, dyskinetic, fast eating syndrome, paralytic, and medical. Twenty-one of the 28 patients were studied by videofluoroscopy and 86% of the videos were abnormal, showing aspiration in eight, webs in five, and delay in the oral phase in five. Patients with bradykinetic dysphagia (secondary to neuroleptic-induced extra-pyramidal syndrome [EPS]) and paralytic dysphagia appeared to experience a more severe form of choking.