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[DYSPHAGIA] Medications

  • Subject: [DYSPHAGIA] Medications
  • From: AWallace@echd.org (Ann Wallace)
  • Date: Thu, 24 May 2001 13:13:32 -0500

Irene, thanks for your input.  Re:  the barium swallow:  the radiologist
wrote "a prominent cricopharyngeus muscle suggesting cricopharyngeal
achalasia".    I will recommend a GI referral.  I had already recommended a
neuological consult and (pat on my back) a careful investigation of this
patient's medications.  

Thanks to all who have responded.  All input is appreciated.


		-----Original Message-----
		From:	Irene Campbell-Taylor [mailto:eripley@yahoo.com]
		Sent:	Thursday, May 24, 2001 11:42 AM
		To:	Ann Wallace
		Cc:	dysphagia@medonline.com
		Subject:	RE: [DYSPHAGIA] Medications

		--- Ann Wallace <AWallace@echd.org> wrote:
		when she had
		> reported no heart
		> problems.  She reported "choking" on all
		> consistencies, noting especially
		> bread.  

		As I said before, the polypharmacy here is amazing -
		several cardiac meds,for hypertension, atrial
		fibrillation, congestive heart failure (probably
		caused by the propanolol),  one for gout, thyroid
		replacement, diabetes ( which is probably a large part
		of her swallowing/esophageal problem), a diuretic and
		a medication affecting the ability to urinate! 
		She needs a referral to gastroenterology ASAP for
		endoscopy if they say they "can't see anything" in the
		traditional barium swallow. The complaint of trouble
		with bread is almost always a dead give away for
		esophageal problems. Her oropharyngeal difficulties
		could very well be a reflection of this or may be due
		to other factors - or a combination.
		Xerostomia affecting the swallow and the esophageal
		clearance is almost a certainty. Almost all
		medications used in the elderly cause xerostomia which
		in addition to the normal reduction of saliva with age
		and, in this case, use of a diuretic, probably leaves
		her dehydrated (is anyone checking?) and always
		disrupts the coordination of the swallow as well as
		esophageal clearance.

		> 	MBS revealed severely decreased anterior/superior
		> hyoid movement
		> with resultant absent epiglottic inversion,
		> decreased laryngeal elevation,
		> and decreased cricopharyngeal opening.  The main
		> problem is vallecular
		> residue which is mild with thin liquid but severe
		> with puree and solid
		> consistencies. 
		I would expect this with poor hyoid movement - no
		opening of the UES so nowhere for the bolus to go. The
		UES on relaxation sometimes will take a little thin
		barium but as the relaxation lasts only about half a
		second it can't handle anything more. One of the
		reasons that very small boluses in VFSS are
		 Successive presentations of solid
		> resulted in a buildup in
		> the valleculae that spilled into the pharynx and
		> resulted in near
		> aspiration.  Only her quick retrieval prevented a
		> large amount of the solid
		> from entering the airway.  In addition, she was
		> unable to propel large thin
		> liquid boluses smoothly through the pharynx with
		> part of the bolus going
		> into the pharynx and the rest being pushed back up
		> nearly into the nasal
		> cavity.  
		> 	There was a prominent muscle bar at the
		> cricopharyngus, and she was
		> having a barium swallow, but I didn't stay for that
		> and don't know the
		> results.  

		Cricipharyngeal bar another reason to suspect GI
		Please keep us posted.


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