FWD: RE: [Dysphagia] Clivial meningeoma & resultant swallow problems

[Paula.Leslie at newcastle.ac.uk (Paula leslie)]

Hello All

Just an update on the responses to this query.  I'll be reviewing the tapes 
with the ENT and Rady this week and will let you know the outcomes...

Paula



>===== Original Message From Valerie DeRooy <vderooy@ckha.on.ca> =====
Yes, feel free to send it on - I didn't think I was offering much so just
sent it to you.  I agree that it is difficult to get the whole picture
without seeing the studies.  It makes it a very difficult guessing game
@times.  The team @ NWU-Chicago may have some helpful info for you as well.
Valerie De Rooy, SLP ? Reg. CASLPO
Speech-Language Pathologist
Chatham-Kent Health Alliance
Phone: (519) 352-6400 ext. 6984
Fax: (519) 436-2500
Email: vderooy@ckha.on.ca <mailto:vderooy@ckha.on.ca>

-----Original Message-----
From:	Paula leslie [SMTP:Paula.Leslie@newcastle.ac.uk]
Sent:	July 8, 2005 12:00 PM
To:	Valerie DeRooy
Subject:	RE: [Dysphagia] Clivial meningeoma & resultant
swallow problems

Hello Valerie

Thank you very much for this.  I guess the big thing for me and a couple of 
others is that hyolaryngeal excursion isn't really discussed.  And the CP
won't open without that.  So yes you would get lots of build up of stuff in
the pharynx.  It's also hard to know what "premature spillage" actually means.
 It's hard when we haven't seen the patient.  I'm gathering info and will 
discuss it with my colleague (ENT) then she will make the decision to request
the patient attends or not.  We also have a very experienced radiologist who
has done +++ VFs with SLPs and is a crucial part of the team.  He would be
involved.

CP myotomy in my limited experience is a serious last resort, particularly
with reflux.

May I cc your response to the listserve?

Thanks again

Paula


>===== Original Message From Valerie DeRooy <vderooy@ckha.on.ca>=====
>Paula,
>To be honest I don't have much experience with patients requiring
>cricopharyngeal myotomy however I am instantly drawn to the point that
>strategies improved the UES opening but not aspiration.  If the pt. is
>aspirating pre & post swallow, is this due to pre-mature spillage into
>pyriform/vestibule? Is aspiration post due to build up @UES?  My instinct
>would be to work on control of bolus & delay in addition to tongue base, if
>that is the cause of aspiration.  Was super-supraglottic swallow tried?
>Just my quick thoughts
>
>
>Valerie De Rooy, SLP ? Reg. CASLPO
>Speech-Language Pathologist
>Chatham-Kent Health Alliance
>Phone: (519) 352-6400 ext. 6984
>Fax: (519) 436-2500
>Email: vderooy@ckha.on.ca <mailto:vderooy@ckha.on.ca>
>
>-----Original Message-----
>From:	Paula leslie [SMTP:Paula.Leslie@newcastle.ac.uk]
><mailto:[SMTP:Paula.Leslie@newcastle.ac.uk]>
>Sent:	July 7, 2005 4:31 AM
>To:	Dysphagia List
>Subject:	[Dysphagia] Clivial meningeoma & resultant swallow problems
>
>Hello All
>This week's puzzle.  My colleague, an ENT surgeon, has been asked to give a
>second opinion on this case.  My colleague has much experience in dysphagia.
>We only have the information below to go on but could request an exam of the
>client if necessary.  Given that this person lives several hundred miles
>away this would be a big step but they are "desperate". My comments are in
>capitals.  The request my colleague got is first, followed by the SLT VF
>Report and advice to client in 2001.  A repeat VF was carried out late last
>year with no change apparently.
>I (and my colleague) would be very grateful as usual for advice/comments.
>Apologies for cross posting if you're on "The List"!
>Thanks
>Paula
>

>***************************************************************************

ENT Summary & Request for 2nd Opinion   2005

In 1997 T had a large clival meningioma resected with associated post
operative bulbar palsy (WOULD THIS CAUSE A PROMINENT CRICOPHARYNGEUS AS IT
SAYS IN THE NOTES?) As a result T was referred to me in 2001 for assessment
and consideration of further treatment.

In conjunction with the SLTs and vf studies, it was concluded that T had
almost absent retraction of tongue base, mild delay in initiating the
swallow, reduced opening of the upper oesophageal sphincter, and there is
complete right pharyngeal hemiparesis. As a result of this we aimed to carry
out further assessment of T's upper GI tract but unfortunately probe
measurements were poorly tolerated and inconclusive. (CONFLICITING EVIDENCE
- POSSIBLE REFLUX EVENTS NOTED ELSEWHERE IN PAPERS. UNCLEAR IF IT IS A
PRIMARY CP MALFUNCTION OR SECONDARY TO POOR HYOLARYNGEAL EXCURSION.)

T was treated for gastro-oesophageal reflux. Once again this had little
benefit. In August 2002 I carried out a rigid endoscopy but it was not
possible for me to pass a rigid endoscope into the proximal oesophagus
because of anatomical difficulties (NO INDICATION GIVEN OF WHAT THESE MIGHT
BE). We will also consider the use of Botulinum toxin and as a precursor to
this, infiltrated the cricopharyngeal region using Lignocaine (LIGNOCAINE
INJECTED INTO THE CRICOPHARYNGEUS I THINK). This did not result in any
benefit. T is now at a stage of considering almost anything to try to
improve swallowing. T has provisionally arranged to have a crichopharyngeal
myotomy, however, given the videofluoroscopic findings I am not necessarily
convinced that this would be of great benefit and I am concerned that this
may be of a detrimental effect to T.  (ME TOO ESPECIALLY WITH REGARD TO
REFLUX!)

*********************************************************************


Speech & Language Therapy Report  2001

Further to our joint consultation with T at the voice clinic a
videofluoroscopic study was conducted. The study demonstrated:

. almost absent retraction of the tongue base . loss of the bolus to the
pharynx . mild delay in initiating the swallow . reduced laryngeal elevation
(I THINK THIS COULD BE THE PRIMARY PROBLEM WITH THE POOR CP OPENING) .
reduced opening of the upper oesophageal sphincter . aspiration of liquid
and paste bolus pre and post swallow . a virtually complete right pharyngeal
hemiparesis . a reasonably strong cough which is effective in clearing some
of the aspirate from the trachea

Several strategies and manoeuvres were attempted during the
videofluoroscopy.
Use of a right head turn in combination with the Mendlesohn manoeuvre was
shown to be most effective in prolonging the opening of the upper sphincter
however these did not eliminate aspiration. T has been advised to utilise
these strategies when attempting to take any oral intake. In addition T has
been issued with exercises which may improve back of tongue movement and
opening of the upper sphincter. It would be useful also to consider pressure
studies of the upper sphincter and possibly the lower sphincter as well as T
reports regular and severe acid reflux. Depending on the outcome of these
studies I wonder if it would be worth considering as a next stage Botox
injection into the upper sphincter with the final consideration of
cricopharyngeal myotomy.

In addition we arranged for T to have a more detailed analysis of speech
with one of our colleagues and it was decided that for the next few weeks T
would focus exclusively on the swallow exercises. May I suggest that we
review T jointly in the voice clinic and evaluate progress with exercises
and decide at that point whether it would be appropriate to give some
further work on speech.

***************************************************************************

Speech & Language Therapy Advice   2001

Dear T

Further to your consultation with Speech & Language Therapy please find
below a list of the recommendations that were discussed with you. We hope
you find these useful and look forward to seeing you again when you are
reviewed.

Recommendations

When attempting to swallow you should :
1. Turn your head as far round to the right hand side as possible.
2. Attempt to keep your Adam's apple in its highest position for 2-3 seconds
longer in order to prolong the opening of the top of the gullet.
3. Carry out on an intensive basis the exercises for the base of your tongue
and the top of your gullet that were given to you on the day.
4. Favour liquids but if trying any thicker consistencies alternate swallows
with small sips of water.

Paula Leslie
Degree Programme Director
Surgical and Reproductive Sciences
Faculty of Medical Sciences
University of Newcastle
Newcastle upon Tyne
NE2 4HH
UK
T +44 (0) 191 222 6279
F +44 (0) 191 222 8988
http://www.ncl.ac.uk/sars/postgrad/MSc.htm