MBS 11-7-07  continued...

 

PHARYNGEAL CLEARANCE (Peristalsis): This patient showed residue <10%) of a small bolus remains in the mid and /or lower pharynx after the first swallow.
ASPIRATION: This patient showed no aspiration on today's evaluation. There is transient laryngeal penetration approximately one-quarter to halfway into the laryngeal vestibule with the patient using her compensatory devices. No swallow are able to be observed without the patient utilizing devices and the head in a neutral position. Once again, she flexes her body completely out of the visual field and takes a swallow with her head by her knees. The patient audibly clears any trace coating that may be on the epiglottis with multiple audible throat clearing responses and strong exhalations after swallow is completed.

PHARYNGEAL/ESOPHAGEAL SEGMENT (Proximal or cervical esophagus; upper esophageal sphincter/UES): This patient showed normal relaxation of the UES; caliber of opening is full.

MODIFICATION(S): The following modifications were tried to prevent aspiration and/or to increase swallowing efficiency:
1. Use of devices as described above help this patient.
2. The patient is spontaneously demonstrating use of a combination of supraglottic swallow and Mendelsohn maneuvers.
SUMMARY AND IMPRESSION: The patient continues to present with  pharyngeal dysphagia and question of dysphagia progressing toward moderate level of dysfunction. The patient is clearly not functioning without the use of multiple compensatory strategies she has developed which include physical manipulation of her neck and throat during swallow by holding wooden devices in submandibular region. This appears to be providing support to the patient's mandible in some way. Today, she was unwilling to attempt to demonstrate a swallow with her head in a neutral position without use of the devices during the time of this evaluation. Therefore clinical statements regarding the patient's natural swallowing function are unable to be made. There is no aspiration today. I reviewed prior results of other studies and there was no aspiration at that time. There were episodes of penetration in the past as they have been seen today and described above. The patient is safely ejecting material which remains in trace amounts on the underside of the epiglottis and does this by throat clearing and cough after the swallows. Please refer to the ASPIRATION section of the report for details.
Because the patient continues to complain of difficulty breathing and maintaining jaw closure at rest, fluoroscopy was undertaken with the patient standing in the lateral and AP projections at rest without use of her devices. Airway and posture is normal for approximately ten to fifteen seconds. Through this time one sees significant posterior tongue retraction and inferior movement so that it does, eventually, close the airway. It actually appears she is "swallowing her tongue". The mandible also drops. When the patient is asked to protrude and push her tongue forward, she does so immediately, but can not/does not raise her mandible. She then doubles over gasping for air. One can not judge via flouroscopy whether this is voluntary behavior of muscle retraction vs. contracture.

*The patient has significant moments of anxiety, distress and difficulty breathing through the evaluation.  She is also seen for 30 minutes post evaluation for further discussion of her difficulties.

PROGNOSIS: For continued p.o. is good with the patient using her strategies, however, I do not think the patient's goal for this evaluation was for just swallowing but also for some ability to improve her functional breathing and I find this difficult to assess.

 

RECOMMENDATIONS:
1. Diet - As tolerated and continue use of her devices and maneuvers that makes the patient feel safe swallowing until an alternative is identified.

Recommend referral for physical therapy for manual therapy and assessment of posture, neck contracture and possibly for biofeedback intervention. MRI of neck to assess for fibrotic changes in neck tissue which is not captured via soft tissue x-ray or CT.
Consider neurology consultation for EMG studies to determine muscle function as patient senses she has some non-functional floor of mouth/neck muscles.

Ideally, the patient might best be served in a setting where she could get a team approach from physical therapy, speech-language pathology to
address the multiple challenges this case presents. It would be helpful if there was a possibility of biofeedback in some form. Some options might include Tufts-New England Medical Center or Mass General Hospital. I do not think the patient would tolerate a Fiberoptic Endoscopic Evaluation of Swallow at this point, but perhaps in the future.Another possibility may be a private practitioner on cape from Speech-Language Pathology Associates of Cape Cod, Dr. Suzanne Miller, 362-3314.
Patient/Caregiver Education: Approximately 90 minutes was spent directly with the patient and all results were discussed. She had a friend also present the entire time. Complete recommendations were not made at that time as I told her I wished to give it more thought.
Case was discussed also with Dr. Gour, in person. Patient has requested a copy of this evaluation and video and she was told it would be made available next week.

Signed Electronically
11/09/07
MARIA LATTA
SPEECH-LANGUAGE PATHOLOGIST
jrr DD 11/09/07 ; DT 11/09/07
cc: NIVEDITA GOUR MD

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