Modified Mondays: Something looks wonky... or does it?

It’s easy to forget sometimes that an MBS study is a 2D image of a 3D action. As such, it can be easy to take a look at an image and struggle to figure out what, exactly, you are looking at. This is one of the many, many reasons why reviewing the study is critical.

Take this week’s case from our Wisconsin office: Patient with a history of COVID-19, pneumonia, GERD, and schizophrenia with complaints of feeling like food is “stuck”. He presented clinically with gagging, decreased PO intake, weight loss and overall decline in strength since his recent second bout with COVID. Our Director of Clinical Services and Operations, Elizabeth Musto, noted incomplete hyolaryngeal movement and base of tongue retraction with resulting incomplete epiglottic deflection. Where it starts to look really interesting is during sequential swallows of thin liquids. During the swallow, if you look closely at the posterior pharyngeal wall, it almost appears to have some irregular soft tissue with barium moving around this anomaly. Upon review, Beth confirmed that in fact, this anomaly was the undeflected epiglottis. This was so interesting to see, since it’s not always visible due to the obscuration of the bolus-and if an SLP sees something like this and doesn’t realize it’s the epiglottis, it could result in more restrictive recommendations pending further work up. The team was able to make solid recommendations for continuing PO, and for therapy targeting base of tongue retraction and hyolaryngeal movement.

The second part of the story that comes from the detailed review was the observation that the epiglottis did also appear a bit edematous, and upon looking at the patient A-P (once again on the importance of the A-P view!), it was also noted that the bolus flow was unilateral. Given all of these findings, plus the patient’s complaints, the gagging, and the weight loss, our team also recommended consideration of a follow up FEES to more closely examine the soft tissue and bolus flow to the pyriforms during the swallow, as well as an ENT and/or GI consult.

The recommendations of the MBS should be comprehensive, they can’t just include a diet and maybe some strategies to use during PO. Follow up care, treatment, and further consultation are all an important part of addressing the patient’s total swallow health.