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[Dysphagia] cough related to eating but not aspiration
Perhaps Gastro could investigate for eosinophilic oesophagitis? It sounds like vagally mediated cough in response to poor motility.
Claire Langdon
Senior Speech Pathologist
Sir Charles Gairdner Hospital
Hospital Avenue Nedlands
West Australia
Phone: 61-8-9346-2044
email: Claire.Langdon@health.wa.gov.au
-----Original Message-----
From: dysphagia-bounces@b9.com [mailto:dysphagia-bounces@b9.com]
Sent: Tuesday, 3 October 2006 01:52
To: dysphagia@b9.com
Subject: [Dysphagia] cough related to eating but not aspiration
Patient profile: 36yr old woman with Type 1 diabetes-poorly controlled
as a child. She has had multiple admissions for hyperglycemic
ketoacidosis although not since 1996. Since 1999 she has developed
frequent insulin reactions with seizures and cyanosis. She is in
chronic renal failure and has diabetic retinopathy. She is also
hypothyroid although well controlled on meds. Meds: Humalog; Insulin;
betamethasone; synthroid; cytomel; oxybutrin; furosemide, Diovan and
metclopramide
She has gastroparesis but does not have any diagnostic signs of reflux
(she has had the full workup). Her "dysphagia" symptoms are as follows:
after eating for a few minutes she begins to violently cough. This
really only occurs with solids-She has the most problems with breads but
of interest she finds that she can manage meat quite well. The client
is devastated by this problem as she is no longer able to go out and eat
socially.
The cranial nerve examination--I tested all 12 nerves-only showed one
finding of potential relevance. Her tongue was weak as evidenced by the
fact she could not hold it steady on protrusion. In addition, lateral
movements were awkward. There was slightly reduced strength against
resistance Lt >Rt . During the interview the client stated that she has
"lots of saliva' but in fact, inspection of the oral cavity revealed she
was tending more towards xerostomia -probably b/c she was NPO for the
test. The client then went on to say that her 4 year old daughter still
drools and her own mother had commented that my client drooled for most
of her childhood.
We began radiological testing by re-doing the upper GI series. As
expected it showed significant gastroparesis. We then began the food
trials. With thin fluids, the mechanics and timing of the swallow were
absolutely normal. Of interest so were the solids-she initiated the
swallow in a timely manner; hyo-laryngeal excursion was complete in both
planes and each bolus passed through the UES and was well into the
esophagus but then she began to cough. There was no evidence of
laryngeal penetration at any time, nor did we detect residue in the
valleculae or pyriforms -nothing that could account for the coughing
bout but yet she coughed and coughed. The cough appears to be
triggered mid-sternum. Obviously with the gastropareis her stomach
appeared full of barium and the lower esophagus was beginning to
fill-but when asked if she felt full, the client denied feeling this
sensation.
My questions to you are as follows. Has anyone seen a similar
presentation? (My understanding is that most people with diabetes have
a higher cough threshold) . Is there anything we could suggest apart
from smaller and more frequent meals to help her? Why is she coughing
with the bolus well into her esophagus? Do you think it may be her
body's attempt to clear food by opening up her LES? Or???
Thank you for any insights you may have
Cindy Reynolds, M.H.Sc.,
Manager, Speech-Language Pathology
Lions Gate Hospital
Assistant Clinical Professor, UBC
604-984-5747
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