[Dysphagia] Difficult case

[pressmah at sjhmc.org (Pressman, Hilda)]

How about trying ice chips or very small amounts of ice water on a spoon after having her mouth cleaned

-----Original Message-----
From: dysphagia-bounces at b9.com [mailto:dysphagia-bounces at b9.com]On
Behalf Of Denise Haas
Sent: Monday, October 30, 2006 9:08 AM
To: dysphagia at b9.com
Cc: Jennifer Klipple
Subject: [Dysphagia] Difficult case


Hi all
I am posting this for a colleague.  Any suggestions are appreciated. 
See below.
Denise Haas
MossRehab Hospital
Elkins Park, PA

This is a 54 year old woman s/p GSW to the head.  The bullet then came
out of her neck on the same side.  She developed acute hemorrhage in her
neck and underwent ligation of the left internal carotid and left
vertebral arteries.  She also had a coil emolization of a right PCOM
aneurysm.  An MRI revealed acute infrarcts in left PICA/cerebellum and
left centrum centriovale.  She has a cervicle fracture and wears a
cervical collar as a result.

Inpatient rehab (9/26-10/6):  A videofluroscopy (lateral view only) on
10/2/06 revealed mild oral and severe pharyngeal dysphagia with
aspiration of material after the swallow.   She was only given one tsp.
puree and one sip of thins.  She was able to trigger a swallow, however,
she had significant pyriform sinus residual and was unable to clear with
multiple swallows.  Some of the bolus passed through the
crico-espophageal sphincter.  The remaining material in the pyriform
resulted in penetration after the swallow with puree and frank
aspiration after the swallow with thins.  The cause of the pyriform
pooling was difficult to determine on the video.  The doctor thought
that she should be further evaluated with another imaging tool
(ultrasound, MRI) in order to assess the pharynx for structural
abnormalities.  This could not be done because she still has a cervical
collar.

When she was an inpatient, she was generally unable to trigger a
swallow when prsented with T-G stim.  She also reported decreased
sensation.  

Outpatient rehab:  Patient just started outpatient therapy 10/23/06. 
She presents with inconsistent wet vocal quality even before
presentation of T-G stim.  She is able to trigger a swallow in response
to T-G stiim after 2-3 second delay.  She also reports increased
sensation.  Occasional coughing and wet vocal quality are evident after
T-G trials.  

I have been very conservative in treating her due to the results of the
videofluoroscopy.  I really don't know where to go from here.  Any
suggestions?  

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