[Dysphagia] Treatment suggestions anyone?

[LSterling at aol.com (LSterling@aol.com)]

Hi All,
 
I completed an OP MBS on a 38 yo patient yesterday who has been on PEG  
feedings since 2004.  She has had multiple trials of therapy and verbalizes  
motivation.  Despite apparently having every tx modality known to our  speciality 
already...I agreed to give her another trial and told her I would be  consulting 
my professional consortium (this list).  I have already prefaced  my 
agreement with concern re: progress given the length of time she's been  
dysphagic...but who am I to kill all hope???
 
Here's the scoop (I apologize for the length):
38 yo F with trigeminal neuralgia s/p radiofrequency trigeminal rhizotomy  x2 
(Translation for those unfamiliar: an electrode was advanced to a particular  
ganglion of CNV and heated to produce thermal injury to the nerve).  She  
developed meningoencephalitis after the second procedure in 6/2004.   Hospital 
course was complicated by cardiopulmonary arrest x2 and bilateral  pneumothorax. 
 She was trached secondary to respiratory failure during that  
hospitalization.  Medical record states hypoxic injury as well.   Sometime during this 
hospitalization she also had CVAs.  Likely associated  with the arrest.  She was 
hospitalized in May 2006 with bacterial pneumonia  which progressed to BOOP 
(bronchiolitis obliterans organizing pneumonia aka  Epler's pneumonia).  MRI at 
that time revealed an a small mid right  thalamic insult and chronic insult in 
the left cerebellar hem (3cm x 5cm in  height).  Increased iron deposition is 
suspected in the deep nuclei of the  left cerebellar hem and a insult in the 
dorsal aspect of the medulla particulary  to the right of midline about 1cm in 
width and heighth.  
 
Oral mech:  Left unilateral weakness of lips tongue  and palate.  Lingual 
atrophy on left.  Motor speech: Mild ataxic  dysarthria with a flaccid component 
c/w her insults
 
MBS -- and doesn't it just figure that this is the day  they break down our 
room to go digital and I am wtihout the ability to tape in  the new room:  She 
was presented with thin and thick liquids and  puree.
Oral Phase:  Decreased coordination consistent with a  cerebellar injury.  
Poor control of liquids.  Essentially ejects  boluses into pharynx with the 
tongue.
Pharyngeal Phase: Has anterior motion of the hyoid...does  not have what I 
would call a complete swallow.  Appears to be more tongue  base movement.  
Boluses pool in valleculae and pyriforms.  Brings  puree and thick back up into 
oral cavity b/c UES doesn't open (no laryngeal  elevation).  Maybe 5% of thin 
liquid passes through UES.  Very  uncoordinated pharyngeal phase as would be 
expected with her cerebellar  insult.  Laryngeal penetration to the level of the 
vocal cords with all  consistencies.  Large amount of aspiration x1 with thick 
liquids with no  cough response at all...not even latently.
 
Past therapies:  Probably everything in our book of  tricks.  During her last 
hospitalization in May was provided with effortful  swallow, Mendelsohn, 
supra superglottic and Shakir.  She reported someone  has done thermal stim as 
well.  Has also had 3 sessions of e-stim at  another facility which she could not 
stand.  E-stim and DPNS are not an  option at my facility.  
 
Any suggestions anyone?  I suspect I am going to end up being the bad  guy 
which is okay.  Been there many times.  Had a soft spot for this  gal.  Just 
thought I would send it out to the general Dysphagia list  membership for 
suggestions!!
 
Thanks!
Laurie Sterling M.S., CCC-SLP
Senior Speech Pathologist
The Methodist Hospital