The amount of time a speech-language pathologist spends caring for patients with dysphagia has increased over the past 20 years. One reason is that referring professionals have increasingly recognized that the range of patient types and diagnoses that can exhibit dysphagia has expanded.
Dysphagia places an SLP in a key role in the patient's health care. Dysphagia is also an area in which problem-solving is critical in diagnosis and treatment. The clinician must understand the nature of the patient's dysphagia and should attempt treatment trials during diagnosis, thereby gathering evidence on the best treatment. The clinician then plays a critical role in the patient's recovery, including coordination of the dysphagia team. All of this must occur rather quickly in an acute care environment, often within four days to two weeks.
Pressures are on in all facilities to decrease the length of stay, thereby reducing costs. This places even more importance on dysphagia and the SLP's role in designing and conducting treatment and coordinating the team effort. This Dysphagia Grand Rounds presents four cases that illustrate various aspects of assessment, treatment planning, treatment, team involvement, and outcome. Questions are asked to stimulate your thinking, with answers on page 18.
A 60-year-old female who has had Parkinson's disease for 20 years, Patient #1 is well educated and comes from an environment of high-powered achievers. Her first symptoms were mild muscle weakness in her extremities that turned into mild difficulty with walking and other physical activities. Secondary symptoms were evident when the volume of her voice became reduced. As soon as her disease was diagnosed she began to take Levadopa orally with good to fair success until three years before her last swallowing evaluation was completed. She noted the following swallowing changes: it took longer to chew, she felt that food caught in her throat, and it took longer for her to complete a meal. What are some of the possible physiological reasons for these complaints?
As her swallowing problems became more pronounced, she noted more tremors in her hands, arms, and neck. Although she would not admit to any memory or cognitive changes, family members noted gradual declines in intellectual function. What are some of the possible effects of cognitive decline that may affect swallowing or swallowing treatment?
Over the last several years, Patient #1's symptoms exacerbated and she received bilateral subthalamic nucleus implants to reduce tremors and improve general level of functioning with only fair success. Speech production was severely affected and she received an augmentative communication system that proved too difficult to use. She then used a spelling board with some success except that her upper extremity dexterity had declined, making it difficult to select letters with any consistency. She has minimal affect, fatigues easily, and closes her eyes when trying to communicate, but has a voracious appetite and wants to eat everything. Her oral motor function was moderately to severely reduced, causing poor lip seal, weak facial and lingual musculature, lingual tremors, oral facial fasiculations, and a hypoactive gag reflex. The cough could not be stimulated voluntarily.
On a series of videofluorographic swallowing studies the following results were noted: lingual pumping, impaired ability to remove a bolus from a spoon, bolus residue on the palate and teeth, severely delayed transfer of a bolus from the mouth to the pharynx (15+ seconds), bolus dripping into the valleculae with penetration of the residue into the airway, and no clearing cough, resulting in aspiration of the bolus for more than half of all ingested material. She takes about an hour for meals and wants to eat everything but cannot feed herself and is at constant risk for aspiration. Her family also wants her to remain an oral feeder. What are the options and what are the drawbacks for continued oral feeding in this progressive condition? What would you recommend to the family?
This case represents an ethical challenge for the SLP in that Parkinson's disease is a degenerative and progressive condition and this individual is placing demands for intervention that may not result in the outcome desired by the family.
A 64-year-old man with a T4 squamous cell cancer at the base of the tongue was treated with a complete course (7000 Rads) of radiotherapy plus concurrent chemotherapy with cis-platin, fluorouracil, and hydroxyurea. He began swallowing treatment after a radiographic assessment was conducted at one month after completion of the tumor treatment. He developed significant mucositis that delayed his swallow treatment to the period post-treatment. This is true of many patients with chemoradiation. At that one-month assessment post-chemoradiation, he exhibited all typical problems of patients who receive this high dose treatment (Lazarus et al., 1996). What are those typical problems?
At the time of his severe mucositis, Patient #2 received a percutaneous endoscopic gastrostomy (PEG) for nutrition because his oral and pharyngeal pain was significant enough that he could not swallow. He continued to use the PEG for the next 10 months. At four weeks after completion of chemoradiation, he began swallowing treatment that focused on improving laryngeal elevation, airway entrance closure, and upper esophageal sphincter opening. Techniques used included the Mendelsohn maneuver, the super-supraglottic swallow, and tongue base range of motion exercises including yawn, gargle, and tongue base retraction (Veis, Logemann, & Colangelo, 2000).
Although Patient #2 exhibited improvement over the next three months, his upper esophageal sphincter was not opening well and he consistently exhibited material remaining in the pyriform sinuses with aspiration after the swallow. He was referred to gastroenterology for assessment. Endoscopy identified a stricture just below the cricopharyngeal region that was dilated. For a short time, he exhibited improvement in his swallow at that level but over the next six months did not exhibit any further improvement. Laryngeal elevation was improved but not enough to open the upper sphincter in the context of the stricture that recurred.
He then began asking for other alternatives. He saw an otolaryngologist who repeatedly conferred with us regarding whether a total laryngectomy was appropriate. We indicated that, because of the increase in pressure generation needed for successful swallow post-laryngectomy, a total laryngectomy was likely not to allow a normal diet, if this was his goal. It would allow him to drink liquids and eat soft foods, however, by eliminating aspiration.
Patient #2 was then counseled by the entire dysphagia team, including the otolaryngologist, gastroenterologist, and SLP regarding his definition of "eating." The patient indicated willingness to eliminate non-oral feeding, realizing that he would lose his voice but could eat liquids and likely soft foods accompanied by liquids. He was counseled that his total laryngectomy would not enable him to eat a normal diet. Why?
With repeated counseling, this patient opted to proceed with the total laryngectomy with immediate surgical voice restoration, which he underwent at 12 months post-chemoradiation. He began to eat liquids and soft foods after the total laryngectomy. He was extremely happy with this change and his immediate laryngeal surgical voice prosthetic procedure. He therefore did not have a delay in return to communication. This was especially successful as his surgery involved a narrow field laryngectomy.
This patient's care illustrates the team approach to managing a severe problem post-treatment for head and neck cancer. The importance of counseling regarding the nature of oral intake after a total laryngectomy post-chemoradiation and its limitations is crucial.
A 53-year-old woman who suffered a brainstem (medullary) stroke and received bedside evaluation at two days post-stroke did not have lateral medullary syndrome. She was admitted to the hospital on the day of her stroke and at that time exhibited significant respiratory and swallowing dysfunction. She had no pharyngeal swallow. Her ability to walk and use her arms was within normal limits. She received a modified barium swallow (MBS) study on day two post-stroke on which she exhibited swallowing characteristics typical of a brainstem stroke at that point post-stroke. Consider what this is and refer to page 19.
At one week post-stroke, her pharyngeal swallow began to reappear. At this one-week MBS, her pharyngeal swallow had returned and exhibited the motor problems typical of a medullary stroke. What are these problems?
She was treated actively with the Mendelsohn maneuver, tongue base range of motion, and airway entrance closure exercises. She received an exercise program for independent practice 10 times a day, five minutes per time. She was discharged from the hospital and followed as an outpatient to assess both her ability to perform exercises and the change in her swallow over time. At three weeks post-stroke, her videofluoroscopic reassessment revealed a functional swallow-that is, no aspiration but more residue and a greater delay in triggering the pharyngeal swallow than would be expected for her age and gender. She began oral intake at that time, exhibited no problems over the next month or two, and on an MBS completed at three months post-stroke, exhibited only mild delay in the pharyngeal swallow with mild residue. She continued to do the swallow exercises throughout this three-month period and maintained a normal diet.
This case illustrates the rapid effect of recovery in sudden onset dysphagia as a result of stroke, head injury, spinal cord injury, or other conditions. It is difficult to assess the effects of the exercise program versus Patient #3's spontaneous recovery on her swallow function. This is an important distinction since it illustrates why pre- and post-swallowing treatment studies do not necessarily provide us with an accurate picture. Conducting interventions during the diagnostic imaging study does account for recovery, however.
A 5-year-old child who was referred to the SLP in a public school because he refused to eat snacks with the other children was noted to be uncoordinated and small for his age. A call to the home and conference with the school nurse revealed that the child may have had anoxia at birth and was initially diagnosed with mild cerebral palsy. He also had been diagnosed with oropharyngeal dysphagia from barium swallow studies done when he was younger and had been treated by a private clinician who worked with him on some of the problems he had with oral feeding. He had several febrile seizures in his first year of life and was intubated for feeding for several months.
In his first year of life, his gastrointestinal development was found to be delayed. He had gastroesophageal reflux disease with some regurgitation into the pharynx and was agitated during attempts at oral eating. Weaning him from a feeding tube proved difficult, and he did not like anything in his mouth or anyone touching his face. Later, he resisted having his teeth brushed and would spit out certain foods. He was noted to make nonnutritive chewing motions and would suck on clothing or soft toys. He was a bit "floppy" and was not well coordinated during play time at school, so he was not included in some tasks. At parties for children, he did not put anything into his mouth but would smell or lick items rather than taste them.
The SLP found him to be at age level for comprehension with immature articulation and oral tactile defensive behaviors. His tongue and lip movements were slightly slowed during imitation with some overflow motion to the lower face and cheeks. There were no other remarkable findings. Since he had no indications of aspiration, choking, gagging, or pharyngeal signs of dysphagia, Patient #4 was observed in his home environment during casual eating. He was observed to be a picky eater at home who ate selectively. For example, he would eat cheese strips, peeled apple slices, strips of bologna, and soft white bread crusts. He avoided thin liquids and soft foods but occasionally would drink chocolate milk.
The SLP spent time with the mother finding out what her feeding and eating expectations were in regard to her child. The SLP discovered that the mother was highly protective of her son and always acquiesced to his wants, yet was concerned that he did not eat like other children. She was quite permissive and passive and lacked structure in handling him. The clinician decided that this child would be a good candidate for treatment and began with a two-pronged approach of oral tactile desensitization and behavior modification. Do you think these procedures would be effective? What do you think the cause of Patient #4's feeding difficulties might be?
This case illustrates that when dealing with children, problems in oral feeding may be caused by early feeding or medical problems and remediation may involve re-education, parent counseling, and restructuring the environment.
This Grand Rounds provided an opportunity for you to examine your thinking on patients with dysphagia. It is critical that we do not consider swallowing treatment to consist only of a diagnostic study and an indication not to eat. In fact, dysphagia management usually involves diagnosis, treatment, and follow-up exercise or other programs as appropriate for the patient's swallowing disorders.
Question 1: The possible physiological reasons for this patient's findings on the swallowing study that cause her to have oral problems relate to the fact that in Parkinson's, the ability to volitionally control motions of the tongue is often impaired by either hyper- or hypotonic involvement of the musculature. The impulses from the cortex that serve to innervate the tongue are impaired, and we often find tongue ramping as a common inhibitor of the swallow in the oral phase (Robbins et al., 1986). It is also known that Levadopa effects vary with dose and time of dose so that delays in initiation of a swallow can be related to medication as well as to the overall effects of damage to the substantia nigra.
Question 2: Cognitive declines are common in Parkinson's disease as the condition worsens. Because of her problems in memory and cognition, the patient was unable to follow therapeutic suggestions and to retain a sequence of steps on how to swallow. Furthermore, she often forgot that she had food material in the oral cavity and would inhale, thus increasing risk of aspiration of material that was pooled in the valleculae.
Question 3: This patient is at continual risk of aspiration and aspiration pneumonia. The patient and family want her to eat orally and are denying how serious this could be for her overall lifespan and medical condition. The SLP has an ethical responsibility to inform the family of these risks and to recommend non-oral feeding. Specific recommendations regarding the clinician's concerns about the client's high risk of aspiration need to be carefully documented, and written reports should be kept in the medical records and discussed with the family, patient, and physician. If the family decides not to pursue non-oral feeding, the SLP must carefully weigh the risks of continuing to provide treatment to this patient.
Question 1: Typical swallowing problems observed post-chemoradiation include delayed triggering of the pharyngeal swallow, reduced laryngeal elevation, and reduced tongue base retraction. There is also risk of a stricture developing in the cervical esophagus.
Question 2: Pharyngeal pressure needed for swallow increases as food viscosity increases. Chemoradiation treatment to the head and neck results in reduced tongue base retraction causing a reduction in pressure generation during swallow. After total laryngectomy, greater pharyngeal pressure is required (McConnel, 1988). This combination of characteristics results in difficulty in swallowing thicker foods for the patient after chemoradiation.
Question 1: In the first week post-medullary stroke, no observable pharyngeal swallow is seen, though the patient may struggle to swallow, resulting in some laryngeal and pharyngeal movements.
Question 2: Once the pharyngeal swallow returns, there is usually reduced laryngeal elevation resulting in reduced opening of the upper esophageal sphincter, reduced closure of the airway entrance, a unilateral pharyngeal weakness or paralysis, and reduced tongue base retraction.
Questions 1 and 2: This is a case in which an early traumatic feeding situation most likely influenced this child's aversion to oral tactile input and eating. The child also has some problems with oral motor function that may have delayed both speech production and swallowing development (Rosenthal et al., 1995). At this time it appears that the child has developed a set of behaviors over and above the physiological components and is successfully manipulating the mother to acquiesce to his wishes.
The two-pronged approach would be to work on oral motor coordination and reduction of oral tactile hypersensitivity while using behavior modification or psychological principles to shape his behaviors during eating (Evans Morris & Klein, 2000). The mother would need counseling on how to give him structure and consistency for expansion of his food intake at home in coordination with the teacher and clinician at the school.