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Syndrome (LMS)
and Dysphagia:
Literature
Analysis and
Case Studies
Karen Sheffler, MS, CCC-SLP
Carney Hospital
Steward Healthcare
Karen.Sheffler@steward.org
Other Terms in the
Literature
Wallenberg Syndrome
Lateral Medullary Infarct (LMI)
Most common form of a Brainstem Stroke
(Pearce, 2000)
Dysphagia to
solids and liquids
Contralateral impaired pain and thermal Spinothalamic tract and nucleus of cranial
sense over half of limbs and trunk nerve V carrying pain and temperature
sense to the opposite side of the body
However, Neurologist
and SLP noted diplopia,
horizontal nystagmus in
extreme right gaze, and
dysphagia to solids.
Beginning of
Hospital Course
ONSET: Sudden
dizziness, Nausea/Vomiting, Left side
weak & numb.
Bedside Swallow Evaluation:
o Pushed down solids with sips of liquids.
o Needed moist ground.
o Was using large bites and effortful swallows.
Finding the Lateral
Medullary Lesion
No penetration
Oropharyngeal
Dysphagia, or
Oropharyngeal PLUS
Esophageal Dysphagia?
Debate: Is this just a
pharyngeal dysphagia, or a
combination of pharyngeal
and esophageal?
What is causing the UES
dysfunction?
The Debate
OPINION A: OPINION B:
Reduced laryngeal
Weakness and
elevation and mechanical issues
anterior excursion are present, PLUS
Pharyngeal
Cricopharyngeal
weakness and
decreased bolus muscle is actually
pressure spastic,
All deficits reduce Dysfunction in
are spastic.
Martino et al. (2001)
Motility Studies at 8 months post LMI found:
1. Absent pharyngeal contraction 1 cm
above the UES,
2. No effective relaxation of the
cricopharyngeal muscle,
3. No swallow activity at the level of the
UES,
4. No definite contractile activity in the
proximal 6 cm of the upper esophagus
(striated region).
Martino et al. (2001)
Basal UES pressure = 44 mm Hg
(significant resting tone)
However, the patient did have a discrete
proximal pharyngeal contraction at 2.5 cm
above the UES, as well as normal
contractile activity lower in the esophagus
at 8-15 cm (smooth muscle).
LES pressure was WNL at 36 mm Hg.
10 Grain Barium Pill
Robbins & Levine (1993)
62 y/o female with a left LMI secondary to
a left VA occlusion
Bolus flow remained absent due to a
hypertonic cricopharyngeal muscle
Mendelsohn and lingual piston-thrust-
swallow could override the UES high
pressure zone to an extent, but it was still
in the presence of impaired
cricopharyngeal relaxation
Robbins & Levine (1993)
Manometry: UES sphincter pressure was
distinctly abnormal at 130-160 mmHg with
incomplete relaxation
Needed a Cricopharyngeal Myotomy:
approach from the left side of the neck as the
left true vocal fold was found to be paralyzed
Robbins & Levine (1993)
Repeat MBSS after Myotomy:
Increased duration & range of motion of the UES
opening
90% of the small liquid bolus to pass into the UES
However, when the patient was coached to
perform a head turn to the left, use the piston
swallow, and perform the Mendelsohn maneuver,
she swallowed the bolus without any post-swallow
residue in the pharynx.
Robbins & Levine (1993)
Hypopharyngeal suction pump (HSP) needs
cricopharyngeal relaxation as a prerequisite.
Then the hyolaryngeal anterior and superior
excursion can provide the traction to
mechanically open the UES, resulting in a
negative pressure or suction that pulls the
bolus into the esophagus
(Robbins & Levine, 1993)
Robbins & Levine (1993)
Chen, C. & Huang, T. (2008). Lateral medullary infarction presenting contralateral palatal paresis. Acta
Neurologica Taiwanica, 17 (4), 239-242.
Daniels, S.K., Ballo, L.A., Mahoney, M.C. & Foundas, A.L. (2000). Clinical predictors of dysphagia and
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19.
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Ding R., Larson, C.R., Logemann, J.A. & Rademaker, A.W. (2002). Surface electromyographic and
electroglottographic studies in normal subjects under two swallow conditions: Normal and during the
Mendelsohn manuever. Dysphagia, 17, 1-12.
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