Modified Monday: Sometimes dysphagia is really complicated.
Even though here we try to highlight one interesting thing at a time, most of the time our patients have a lot going on. This patient is perfect example. She has a history of lingual and tonsillar cancer and is s/p partial glossectomy. During surgery, patient had respiratory failure requiring eventual trach placement. A PEG tube was also placed. At the time of the MBS, the patient had been improving medically and recently decannulated.
You can see in the video clip the extensive surgical clips, as well as the smaller than normal tongue bulk. During the study, the airway protection is not perfect, nor is the closure of the V-P port. There is penetration and aspiration. It would be easy to say “Study complete!” and recommend continuing with NPO. Buuuutttt… the patient is cognitively normal, walking around, great oral hygiene, lungs clear…. and desperate to eat and drink ANYTHING (she confessed to our SLP that she had been “sneaking” water and some ice cream). So, as we always do, our SLP looked for strategies that might be helpful for this patient’s physiology.
The patient had difficulty with A-P propulsion of the bolus due to the partial glossectomy, so a tilted back head posture was examined. A chin down, voluntary throat clear, with a secondary swallow-add in an effortful swallow… and the patient was clearing the bolus and protecting the airway significantly better. It’s still not perfect-but our SLP, the patient and the facility SLP all agreed that it was a viable solution to allow some PO.
Swallowing, dysphagia, aspiration, pneumonia, our patients-none of these things are just black and white. There’s just no good formula that says “If A happens on the instrumental and B happens clinically, you need to recommend X plan of care”. Using critical thinking about the patient as a whole, combined with the data we gather is complicated and messy… but it can result in a very simple outcome: a happy patient with an appropriate plan of care.
See the links below for some more thoughts on how complicated dysphagia can be:
Predictors of Aspiration Pneumonia: How Important Is Dysphagia? (umich.edu)
Pneumonia: Factors Beyond Aspiration | Perspectives on Swallowing and Swallowing Disorders (Dysphagia) (asha.org)
(PDF) Comparison of 2 Interventions for Liquid Aspiration on Pneumonia Incidence A Randomized Trial (researchgate.net)