[Dysphagia] case for consultation

[astapane at spark.net.gr (Lucky Luck)]

I d like to hear some suggestions about a case of mine dear collegues
Woman 50 years old , operated 30 yrs ago for osteoblastoma of the 
cervical vertebra, the reoperated 1 yr later for recurence and did 
radiotherapy in cervical region transoraly.
5 years ago she developed "osteonecrosis" (as she said?)  and shortly 
after healing of her ulcerated lession she developed dysphagia in solid 
and needs water to bring the swallowed material down.
In oral exam there is a fixation of the posterior wall of left 
hemipharynx and shows rather a  fixation of the left levator palatii 
(during "aaa" phonation)
We did an VFSS and showed fixation of the post pharyng wall ,no moving 
to meet post tongue during oral thrust, resulting in pooling in 
valecullae.Pooling was progressively worse with yogurt and solids. 
Patient cleaned residue effectively with second dry swallow with liquids 
, but required 3-5 swallows with yogurt and more than 6 with 
regurgitation in mouth with solids.
We tried chin tuck , alone or in combination with right turn, effortful 
swallow and  even therm stim with no effect. 
Lastly some success was achieved with the placing of the solid bolus on 
the right part of the tongue and in combination with a right head tilt , 
resulted in better  thrust of the bolus through the upper pharynx.
Pooling in piriform sinuses was negligible.
Would anyone suggest a better compensatory strategy?

Lukas Dagdilelis MD
Radiologist
Gen Hosp Papanikolaou
Thessaloniki
Greece