Modified Monday: Normal is a myth? Or more common than we think?

SLPs assessing swallowing often start from a place of bias-we are typically looking for pathophysiology, and sometimes we find it even when it's not there. We don't get a lot of training and exposure to normal swallowing, so it can be easy to overdiagnosis a patient with dysphagia.

This clip is a perfect example. Clinical swallow eval noted "slow and disordered mastication" and "delayed swallow onset". Thankfully, before downgrading the diet

the facility SLP recommended an instrumental assessment. On the MBS, our Chicago team did see mastication that was slow, extensive and disorganized. The patient even states "Oh, I know I take a long time to chew." What the team also saw was a large lobular torus palatine. These benign bony growths can be common, are often there from a young age, and take some extra work to manipulate food around. If we look at the patient's mastication in isolation, it's a pathophysiology. However, if we look at the extensive manipulation in the context of the patient and their unique anatomy, it's completely normal and doesn't need to be addressed with an altered diet or therapy.

The range of normal in swallowing often overlaps with pathophysiology, and the only way to separate the two is to look at the anatomy and physiology of the whole patient-considering medical status, history, and patient report. Looking at the "data" of physiology in isolation can lead SLPs to overdiagnose, overtreat, and unnecessarily impact the patient's quality of life and even medical status.

(Apologies to the musical: The Lightning Thief for the title of this post-fun show, highly recommend)