Idea Transcript
Improvement of Dysphagia Following Unilateral STN DBS: Case Report Donna C. Tippett, M.P.H., M.A., CCC-SLP1,2 Zoltan Mari, M.D.3 Bronwyn Jones, M.D.4 Departments of Otolaryngology—Head and Neck Surgery1, Physical Medicine and Rehabilitation2, Neurology3, and Radiology and Radiological Science 4 Johns Hopkins University
Deep Brain Stimulation
Subthalamic Nucleus
DBS Electrodes
DBS Extensions
Implanted Pulse Generator
Effects of DBS • Positive – Improved motor function – Improved ADLs – Reduction in medication dose
• Negative – Neuropsychiatric effects – Depression – Cognitive dysfunction
De Gaspari et al, 2006; Krack et al, 2003; Rodriguez-Oroz et al, 2005; The Deep Brain Stimulation for Parkinson’s Disease Study Group, 2001; Zibetti et al, 2007
Effects of DBS • No change re: gait and balance • Mixed findings re: speech and swallowing
Ciucci et al, 2007; Gentil et al, 2000; Krause et al, 2004; Ostergaard & Sunde, 2006; Tornqvist et al, 2004; Zibetti et al, 2007;
Case Report • 41 yo woman with tremor predominant, right side predominant advanced PD • Narrow therapeutic window • Severe motor fluctuations with dyskinesias and wearing off
Case Report • Initial VFSS – Lingual pumping – Piecemeal deglutition – Loss of bolus over BOT – Sluggish epiglottic tilt – Absent superior pharyngeal constriction
– Reduced middle pharyngeal constriction – Present inferior pharyngeal constriction – Pharyngeal retention – No penetration/ aspiration – Esophageal spasm – Delayed emptying
Case Report • Second VFSS – Fine lingual tremor – Loss of bolus anteriorly and in FOM – Delayed swallow response – Sluggish epiglottic tilt – Absent superior pharyngeal constriction
– Reduced middle and inferior pharyngeal constriction – Early closure of the CP – No penetration/ aspiration – Esophageal spasm – Delayed emptying
Case Report • Unilateral left STN DBS performed • PD motor related dysfunction improved post op on right side • Bradykinesia and tremor reduced while off medication • Dyskinesias reduced on right side while on medication • Midline and left side motor functions were not changed
Case Report • Post DBS VFSS – Piecemeal deglutition – Loss of bolus into FOM – Delayed transfer into pharynx – Sluggish epiglottic tilt
– Asymmetric pharyngeal constriction – Better constriction on right than left – Esophageal spasm – Delayed emptying
Conclusions • Pharyngeal asymmetry not documented on pre DBS VFSS, but observed on post DBS VFSS • Asymmetry corresponded to improved right sided motoric function
Conclusions • Ciucci et al, 2007 – Compared DBS on and off during VFSS – During DBS on • Improved pharyngeal transit time • Improved pharyngeal clearance • Less laryngeal penetration/aspiration
Conclusions • Neuronal activity increased in STN in parkinsonian monkeys (Vila et al, 1997) • Parkinsonian symptoms ameliorated in monkeys after lesioning GPi (Lonser et al, 1999) • STN and GPi DBS produce benefit by interfering with abnormally increased excitatory activity
Conclusions • Pathologically increased inhibition of thalamus is diminished • Thalamic disinhibition allows restored motor function through excitatory thalamocortical circuits
Conclusions • DBS may reduce pharyngeal hypokinesia or bradykinesia – Pharyngeal transit time – Pharyngeal constriction – Pharyngeal retention
• Consider this effect in pre-DBS evaluation