As a mobile provider, one thing I have really missed out on is the long term relationships with patients that I used to love in outpatient and skilled nursing care. I loved the feeling of getting to really know patients, to encourage them, but most of all I loved watching them recover. We don’t often get the chance to see what becomes of our recommendations, or if they even have a follow up study. Often, the patient will be discharged from the SNF, and then the follow up is done as an outpatient in a hospital setting.
This particular case was an exception, and it’s also worth sharing because it’s an interesting finding, and it highlights how important it is to repeat instrumentals… as well as having (spoiler alert) a happy ending. The patient was seen initially with complaints/symptoms including shortness of breath with PO, coughing, and hx of respiratory failure. The initial MBS showed a large, bridging osteophyte. You can see there is incomplete base of tongue retraction and airway closure, with residue post swallow. Aspiration with a pretty good cough response. The patient also appears to be putting a lot of effort into breathing. Our MBS Envision SLP made the ENT consult recommendation, and ultimately the decision was made for an osteophytectomy.
During recovery the patient experienced several complications, including respiratory failure with hypoxia, which then required a trach. An abscess in the poster pharyngeal wall developed, which complicated matters. Four months from the initial MBS, we were called in for the follow up. The patient was medically stable, still with a trach, and had been trialing some PO with no overt signs or symptoms. The follow up study still shows some timing issues and incomplete airway closure, as well as aspiration. In this study, the cough was cued by the SLP, the patient had no spontaneous cough.
This follow up was important, because it was a great example of how just removing the osteophyte doesn’t immediately (or sometimes ever) eliminate the dysphagia, and how response to aspiration can change as a patient’s medical acuity waxes and wanes. Unfortunately, shortly after the follow up, the patient experienced a PEA cardiac arrest episode with respiratory failure after discharge. He was subsequently readmitted, stabilized and was improving in cardiac rehab and with Speech Therapy. We were called again for the referral, and this time…. a beautiful swallow. I was lucky enough to be the assessing SLP for this final study, so I got to be the one to tell him the good news. I had been discussing his case with the prior evaluating MBS Envision SLPs, as well as the facility treating SLP, so I knew how long the road had been for this fellow. Needless to say, he was ecstatic and thanked me several times. I wish I could say that I didn’t take all the credit, but….. I mentioned how much I have missed that patient/therapist relationship status, right?? Can you blame me? Just this once…
*A couple notes on this video, each study is preceded by a graphic letting you know which study you are watching. In the second study, the patient positioning was very difficult as he was in a specialized wheelchair and we were unable to view the oral cavity as we usually do.
Check link below for info on osteophytes and osteophytectomy: