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Modified Mondays: Looks bad on paper

There are certain patients that we just KNOW are going to look really impaired on instrumental. This nice lady from Pittsburgh was a great example of that. She had a history of oral cancer, was status post R partial maxillectomy with extensive resection throughout the oral cavity and into the pharynx. She had recently undergone reconstructive surgery of the maxilla, and had a trach-size 8 Shiley. Currently NPO… and desperate for something to drink. The reconstruction was only just a couple weeks prior (she still had quite a bit of swelling on the right side of her mouth, and the facility SLP was thinking this would just be a good baseline study, probably not with a good immediate result.

To the pleasant surprise of all involved, the patient had not only good airway protection and clear of the bolus, but was also able to masticate fairly well when given a little extra time. This video clip shows the mastication first, followed by thin via straw, then finishes up with an A-P view in which you can see how beautifully she was able to pull the bolus together on her left side orally.

Patients with resection and reconstruction take a bit of problem solving-for this patient you can see in the sips of thin that the straw is inserted fairly far posteriorly, this allowed her to control more easily, since she had difficulty with lip closure (the posterior insertion made it possible to form a seal around the straw with her tongue against the palate on the left side). These patients also require an understanding from the assessing clinician that this is their “new normal” – the patient here may never have a “perfect” swallow, but normal isn’t always perfect.

After this study, we were able to recommend thin liquids with the straw placed posteriorly, as well as soft solids (IDDSI 6-soft and bite sized), which the patient happily agreed with.

Sometimes it takes a study like this to remind us of why we need imaging. Had we assumed, based on “paper”, that the patient had severe dysphagia and potentially aspiration, we would have kept the patient NPO, putting her at risk for complications like infection and dehydration, as well as making her unhappy. Imaging is always important to complete the picture of the patient… and often tells a different story than we expect.

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