Modified Mondays: There’s no such thing as TMI in dysphagia assessment
Updated: Sep 13, 2022
I have discussed here before (once or twice) how nonspecific dysfunction of the cricopharyngeal muscle can look on the MBS study. (To save you from looking at prior MM if you’re short on time-clearance of the bolus through the PE segment is dependent upon: 1) adequate relaxation of the CP 2) adequate traction applied to the CP to open it provided by the movement of the hyolaryngeal complex and 3) propulsion of the bolus thanks to gravity and the work of the pharyngeal constrictors. Dysfunction of any of these factors can be “compensated” for by the strength of the others… so you can’t really tell just from an MBS study what the real problem is. Please feel free to read other MM, though!) We recently had a patient in Cleveland that was a great example of this… as well as a good time to chat about the importance of gathering all the information possible about a patient.
For this patient, we had the luxury of knowing that she has a history of CP dysfunction prior to completing the VFSS study. She had a history of radiation treatments secondary to intestinal CA, with subsequent scarring and then incomplete relaxation of the CP. She had several dilations previously. A few weeks prior to her study, she had quite a bit of coughing “post swallow” and required several swallows per bite. She also had significantly decreased PO intake and weight loss, citing difficulty swallowing and pain with swallow.
The study showed little to no clear of the bolus through the UES, with aspiration on all consistencies and no strategies or positioning were helpful. Our excellent Cleveland SLP, Angie, took into consideration the history, the clinical eval and her own MBS results and recommended the patient schedule a follow up with the treating GI physician as soon as possible. We sent the study to the GI and the patient was seen very shortly after. We did hear that the physician recommended the patient consider botox or myotomy... but we did not have follow up after that, as the patient was discharged from the facility to outpatient care.
For this patient, having the entire picture was crucial to arriving at the best plan of care. Had we only had the clinical information, (and no VFSS data or medical history) an SLP may have easily thought the post swallow coughing and multiple swallows per bit were due to a pharyngeal weakness and may have tried a few weeks of therapy. Similarly, had we the VFSS but no history, we would have still recommended the GI consult, but perhaps not as urgently-since the airway closure was also impaired, we would not have been able to know if the images reflected CP dysfunction or impaired hyolaryngeal movement.
All information is good information when it comes to determining a plan of care. The medical history, clinical information and VFSS results are all needed – as well as patient perspective (which we did not discuss here, but the patient did tell our team repeatedly during the study that she could not swallow and felt like she needed “stretched again”). Thinking of all these factors during assessment is critical to comprehensive and appropriate recommendations.
An overview of the upper esophageal sphincter, Current Gastroenterology Reports | 10.1007/s11894-000-0059-z | DeepDyve
Evaluation of Upper Esophageal Sphincter Function (asha.org)