What is the role of speech and swallowing therapy in the treatment of vertebrobasilar stroke?

Updated: Mar 03, 2020
  • Author: Vladimir Kaye, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Answer

Speech therapy (ST) is used for cognitive retraining, speech and language skills, safety skills, swallowing assessment, and family training. In patients with dysphagia from brainstem lesions, the cricopharyngeus muscle may fail to open sufficiently, resulting in an impaired passage of the bolus from the pharynx to the esophagus. Increased pooling of a bolus in the vallecula and/or pyriform sinuses, which spills into the airway, poses a significant risk for aspiration and pneumonia.

Evaluation of these patients should be thorough and should include a videofluoroscopy with a modified barium swallow to assess for silent aspiration. The speech and language therapist often performs the initial swallowing evaluation and determines the risk for aspiration and the consistency of the patient's diet.

The patient's vocalization and possible reading, writing, and processing deficits also are addressed. Interventions for the prevention of aspiration include compensatory strategies, such as oromotor exercises and postural changes while swallowing, as well as facilitative strategies (eg, modification of bolus consistency, volume, delivery).

Surface electromyography biofeedback for dysphagia has shown promising results. Surface electromyography is used in training a patient to perform maneuvers that compensate for the weak swallow.

The Mendelsohn maneuver, for example, requires voluntary maintenance of the thyroid cartilage in an elevated position for a few seconds, resulting in further widening of the opening of the cricopharyngeus muscle and easier passage of the food bolus through to the esophagus. The patient observes the plateau (as opposed to the peak) of the generated waveform on the screen, reinforcing the concept of muscle activation in the desired position (thyroid cartilage elevation).

The patient should be on a nothing-by-mouth restriction until the swallowing mechanism has been assessed and cleared and the airway has been protected. If there is a high risk of aspiration, a nasogastric or nasoduodenal tube should be placed, although neither completely eliminates the aspiration risk. If the swallowing abnormalities are so severe that recovery is expected to take weeks or months, then a gastrostomy tube should be placed either surgically or percutaneously.

If there is persistent cricopharyngeal dysfunction on videofluoroscopic modified barium swallow, then cricopharyngeal myotomy can be considered. [42]


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