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[Dysphagia] Dysphagia Digest, Vol 39, Issue 20
Has anyone considered MS in this equation?
Melissa Zilberstein
>From: dysphagia-request at b9.com
>Reply-To: dysphagia at b9.com
>To: dysphagia at b9.com
>Subject: Dysphagia Digest, Vol 39, Issue 20
>Date: Mon, 19 Feb 2007 12:00:01 -0700
>
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>Today's Topics:
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> 1. Re: Chronic Dysphagia Laryngospasm (Jai Gupta)
>
>
>----------------------------------------------------------------------
>
>Message: 1
>Date: Mon, 19 Feb 2007 09:17:31 +1100
>From: "Jai Gupta" <Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU>
>Subject: Re: [Dysphagia] Chronic Dysphagia Laryngospasm
>To: "Michael Towey" <speech at wcgh.org>, "Dysphagia List"
> <dysphagia at b9.com>
>Message-ID: <88EEDD02C11B6A4182DD21E42394DCFE127AAA at sesahs.nsw.gov.au>
>Content-Type: text/plain; charset=iso-8859-1
>
>
>Hi Michael,
>Looks like you have done all ...I had a similar case once from psychiatry
>....once they was treated for reactive depression by ECT she became
>perfectly normal after that and symptoms of dysphagia never returned. Ask
>you Psychiatrist what he think?
>
>
>
>
>Jai Gupta. M.Sc.(S.H.) CPSP MSPA
>Manager, Speech Pathology Department
>The Sutherland Hospital
>* Locked Bag 21, Taren Point NSW 2229 Australia
>* +612 9540 7111 page 594 or Direct +612 9540 7558
>*+612 9540 7717 *+61 0401 373 324
><mailto:Jai.Gupta@ sesiahs.health.nsw.gov.au>
>
>A Thought
>
>You see things; and you say, "Why?" But I dream things that never were; and
>I say, "Why not?" ...... George Bernard Shaw
>
>
>
>
>
>
>
>
>
>-----Original Message-----
>From: dysphagia-bounces at b9.com [mailto:dysphagia-bounces at b9.com]On
>Behalf Of Michael Towey
>Sent: Sunday, 18 February 2007 1:23 AM
>To: Dysphagia List
>Subject: [Dysphagia] Chronic Dysphagia Laryngospasm
>
>
>
>
>We have an interesting and unusual case recently evaluated and need some
>help.
>
>47 y/o female nurse. Chronic (25 year) HX of dysphagia, difficulty
>getting food down, she chews and chews, difficultly initiating swallow,
>when she swallows, the 'food stops and gets stuck." She notes pill
>dysphagia as a child.
>
>Also, she has had laryngospasm about 1 X per month, primarily related to
>swallowing, for many years, she just 'relaxes' and it goes away.
>Recalls onset of laryngospasm 25 years ago waking at night with a
>laryngospasm prior to her marriage. Never been worked up, but no other
>HX of any disease, illness.
>
>Apparently healthy woman with nothing in her medical history. Working
>regularly as nurse. She denies any hx of physical/sexual abuse.
>
>Recently, increase in frequency and severity laryngospasm, she feels
>like there is a "splash of saliva" that triggers it.
>
>Laryngospasms have increased, most related to eating, patient is clear
>she feels s 'splash of secretion" prior to the onset
>
>Presently, she is unable to eat, just cannot complete swallow. May take
>1-2 hours to eat serving of yogurt. No other history, no meds.
>
>Has not been worked up by neuro or by GI.
>
>Swallow study with FEES IDs normal pharyngeal/laryngeal function, with
>delayed initiation of swallow - mild premature spillage that stays in
>vallecular prior to swallow. We did catch a laryngospasm during
>endoscopy - she had been instructed in a management technique of the
>laryngospasm prior to the FEES and was able to very effectively manage
>the episode. Laryngeal mucosa looks OK. No laryngeal irregularities,
>VFs look pretty, no edema, no erythema, well hydrated, no throat
>clearing, no dysphonia.
>
>There is a suspicious collection of white, thicker secretions that
>appeared to arise from subglottic area during a swallow/cough
>(difficult to be fully certain due to obliteration of view during
>swallow), that then seems to stay in the interarytenoid space and area
>of UES. Very hard to tell if this is a reflux event.
>
>A MBS was done at another facility, identified 'premature spillage" but
>exam was not recorded. Reflux symptoms are negative (no throat clearing,
>no dysphonia, no c/o excessive secretions, no VF tissue changes). Reflux
>Symptom Index negative.
>
>Her swallow characterized by excessively long oral preparation,
>effortful swallow initiation, the feeling of the 'swallow stopping and
>food getting stuck'. Reflexive swallow of secretions is occasionally
>effortful, often WNL. No dysarthria, oral motility wnl.
>
>After FEES, she was able to complete a number of very successful
>swallows with instruction; left feeling very positive, then problem
>progressed.
>
>She has lost 15-20 lbs in last year due to decreased p/o intake (not a
>large woman to begin with), 14 additional lbs in last couple of weeks
>and is giving herself fluid IVs. Feeling desperate (both of us!).
>
>She is HIGHLY anxious, distraught, fearful. She repeatedly says the
>anxiety is an overarching concern. Referred for psych consult, on
>Klonopin (two weeks), no apparent effect.
>
>Her MD reports lab values re: nutrition look fine although she is self
>administering fluid IVs. And here's an interesting image to give to a
>patient. When she voiced deep concerns about her nutrition, her MD
>assured her she was fine, reminding her that "concentration camp
>survivors went months without food." Needless to say, that didn't lend a
>real boost to her confidence about this problem,
>
>Yesterday she received a PEG. It was very painful for her, meds did
>not diminish her anxiety or comfort level. A few stomach polyps were
>noted and the GI doc noted "No esophageal peristalsis during the
>endoscopy."
>
>Here's what we've doing/recommending to her MDs: 1. Consider 2 X day
>PPI. Symptoms at least in part suspicious for reflux related event. 2.
>Seek counseling for management of anxiety and any other related psych
>needs. 3. Repeat MBS to get complete exam of oral pharyngeal and
>esophageal function. 4. Neuro, GI consults.4. RX consists of working to
>increase speed of initiation of swallow reflex, thermal stim,
>progressively tighten/relax oral structures. Anterior-posterior, attempt
>maintain laryngeal elevation during swallow, try different bolus sizes.
>Get back to more automatic, sequential swallow (anxiety is really in
>the way.)
>
>This lady very discouraged, anxious and feels helpless and unsuccessful.
>
>
>I know psych hx and chronicity are powerful negative prognostic
>indicators -however, this is a young, productive patient.
>
>What are we missing here? Anyone have any suggestions? Any thoughts on
>electrical stim?
>
>
>Michael Towey, CCC-SLP
>Voice & Swallowing Center of Maine
>Belfast, Maine
>207-338-9349
>
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>End of Dysphagia Digest, Vol 39, Issue 20
>*****************************************
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