[Dysphagia] recommendations requested

[msheldon at uci.net (melody sheldon)]

describe the patient's vocal quality.  you mentioned that the cough was
ineffective.  was a chest  xray obtained?
----- Original Message -----
From: "Julie Speech" <speechhuffman@nc.rr.com>
To: <Dysphagia@b9.com>; "Keri Vasquez" <kvasquez21@yahoo.com>
Sent: Friday, September 08, 2006 1:56 PM
Subject: Re: [Dysphagia] recommendations requested


> Hi Keri,
>
> This patient's dysphagia would appear primarily esophageal with
> oropharyngeal symptoms (i.e. he aspirates as a result).  It is not likely
> acute (probably age related and came on gradually would be my guess-- but
> also may be related to reflux).  The results of the esophagram are
> consistent with his complaints- tertiary contractions- especially
> "extensive" means spasm of the esophagus, non-propulsive. This would
> certainly give you solid food dysphagia, occasional trouble with liquids,
> regurgitate at times and would likely make you aspirate when the esophagus
> doesn't clear.  In layman's terms- if the pipes get backed up down below
> (the esophagus), the bolus remains in the pharynx and is more likely to be
> aspirated.  I am not sure what is meant by "exaggerated contraction of the
> UES" but I would think that means hypertension of the cricopharyngeus
which
> is also descriptive of the "cricopharyngeal prominence".  This often comes
> first and will end up creating a Zenker's as this is an area of weakness.
> This leads to increased compliance through the UES and makes more of the
> bolus remain in the pharynx.  For CP hypertension, he may benefit from
> management of this, including reflux modifications or medical management,
> Botox or dilatation of this area if he were a candidate.  In any case, he
> certainly has more than one issue here that would be consistent with his
> subjective complaints.
>
> While he may be at risk for aspiration given his esophageal dysphagia,
> thickened liquids are a mistake.  Esophageal clearance will be worse.
Keep
> in mind that the VFSS is supposed to identify the physiology behind why
the
> person is having trouble, not just what consistency he aspirated.  I would
> bet that given the amount of residual he had with thicker consistency, he
> would eventually aspirate this as well.  Aside from a GI consult to
question
> the above (a general referral for GI is not as helpful as questioning some
> of the things I mentioned above), I would consider-
> - Warm fluids with meals (i.e. warm decaf tea or warm water) avoiding cold
> as this decreases spasm and increases esophageal clearance
> - Reflux diet and precautions as well as aspiration precautions
> - Pharyngeal exercise program- may as well beef up the pharyngeal
> musculature in hopes of compensating for the deficits below
> - aggressive oral care
> - soft diet with thin liquids, water being best choice, avoiding tough,
> fibrous solids
> -  may help to crush pills, but need lots of water to follow to make sure
> they clear the esophagus- not to add localized esophageal injury to his
list
>
> I tend to think you have enough to go on with both the studies you
> mentioned, even if the VFSS wasn't as complete as perhaps it could have
> been.
> Sorry for the lengthy response, I am passionate about this topic and have
> been for years.  That is why I have self-educated in regard to esophageal
> issues and their effect on all aspects of swallowing.  Thank goodness the
> patient refused NPO status.  We owe it to our patients to know this stuff
> and not negatively impact their quality of life with our recommendations.
> Kudos to you for looking further into the situation on behalf of your
> patient!  If you are interested, I teach a 2 day course on the topic and
> would be happy to pass on the information!  Good luck!  :o)  Julie
>
> ----- Original Message -----
> From: "Keri Vasquez" <kvasquez21@yahoo.com>
> To: <dysphagia@b9.com>
> Sent: Friday, September 08, 2006 11:29 AM
> Subject: [Dysphagia] recommendations requested
>
>
> > To all the gurus:
> >
> >  New admit to my sub-acute facility, 86 yo male who was hospitalized w/
> > chief complaint of progressive dysphagia over 3 weeks( solids >liquids).
> > Pt had subjective complaints of "food getting stuck and coughing food
up."
> >
> >  During hospitalization pt had VFSS and esophogram.
> >
> >  Report for the VFSS:
> >  Pt. only given nectar and honey thick barium w/ aspiration of nectar
and
> > ineffective cough.  Chin tuck does not prevent aspiration.  With honey
> > thick barium, pt has mod residue in vall. and piriform that is partially
> > cleared w/subsequent swallows but no evidence of laryngeal pen/asp.
There
> > is cricopharyngeal prominence.
> >
> >  Report for esophogram:
> >  There is exaggerated contraction of the UES w/ adjacent small
> > outpouching, likely representing a Zenkers.  There is a lack of normal
> > esophageal peristalsis w/extensive tertiary contractions.  Contrast
flows
> > into the stomach without any evidence of obstruction.
> >
> >  This pt. was recommended NPO by the hospital SLP in which he refused.
He
> > was admitted here on a puree diet and honey-thick consistency.  Pt.
> > refused EGD.  KUB was negative.  Pt denies any relfux symptoms and is
> > currently taking pepcid.
> >
> >  1. What should I do with this patient?  I feel the VFSS is incomplete
and
> > lacks appropriate information.  Uncertain why no swallow maneuvers were
> > introduced and the drastic conclusion to make this pt NPO.
> >  We have the mobile VFSS available and contemplating to have a repeat
> > study to obtain a full and complete report.
> >
> >  Any comments/suggestions are greatly appreciated!
> >
> >  Keri Miloro, MS, CCC-SLP
> >  Boston, MA
> >
> >
> >
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