[Dysphagia] Clivial meningeoma & resultant swallow problems

[Paula.Leslie at newcastle.ac.uk (Paula leslie)]

Hello All

This week's puzzle.  My colleague, an ENT surgeon, has been asked to give a
second opinion on this case.  My colleague has much experience in dysphagia.
We only have the information below to go on but could request an exam of the
client if necessary.  Given that this person lives several hundred miles away
this would be a big step but they are "desperate". My comments are in 
capitals.  The request my colleague got is first, followed by the SLT VF 
Report and advice to client in 2001.  A repeat VF was carried out late last 
year with no change apparently.

I (and my colleague) would be very grateful as usual for advice/comments.  
Apologies for cross posting if you're on "The List"!

Thanks

Paula

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ENT Summary & Request for 2nd Opinion   2005

In 1997 T had a large clival meningioma resected with associated post
operative bulbar palsy (WOULD THIS CAUSE A PROMINENT CRICOPHARYNGEUS AS IT 
SAYS IN THE NOTES?) As a result T was referred to me in 2001 for assessment 
and consideration of further treatment.

In conjunction with the SLTs and vf studies, it was concluded that T had
almost absent retraction of tongue base, mild delay in initiating the swallow,
reduced opening of the upper oesophageal sphincter, and there is complete
right pharyngeal hemiparesis. As a result of this we aimed to carry out
further assessment of T?s upper GI tract but unfortunately probe measurements
were poorly tolerated and inconclusive. (CONFLICITING EVIDENCE ? POSSIBLE
REFLUX EVENTS NOTED ELSEWHERE IN PAPERS. UNCLEAR IF IT IS A PRIMARY CP 
MALFUNCTION OR SECONDARY TO POOR HYOLARYNGEAL EXCURSION.)

T was treated for gastro-oesophageal reflux. Once again this had little
benefit. In August 2002 I carried out a rigid endoscopy but it was not
possible for me to pass a rigid endoscope into the proximal oesophagus because
of anatomical difficulties (NO INDICATION GIVEN OF WHAT THESE MIGHT BE). We 
will also consider the use of Botulinum toxin and as a precursor to this, 
infiltrated the cricopharyngeal region using Lignocaine (LIGNOCAINE INJECTED 
INTO THE CRICOPHARYNGEUS I THINK). This did not result in any benefit. T is 
now at a stage of considering almost anything to try to improve swallowing. T 
has provisionally arranged to have a crichopharyngeal myotomy, however, given 
the videofluoroscopic findings I am not necessarily convinced that this would 
be of great benefit and I am concerned that this may be of a detrimental 
effect to T.  (ME TOO ESPECIALLY WITH REGARD TO REFLUX!)

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Speech & Language Therapy Report  2001

Further to our joint consultation with T at the voice clinic a 
videofluoroscopic study was conducted. The study demonstrated:

. almost absent retraction of the tongue base
. loss of the bolus to the pharynx
. mild delay in initiating the swallow
. reduced laryngeal elevation (I THINK THIS COULD BE THE PRIMARY PROBLEM WITH 
THE POOR CP OPENING)
. reduced opening of the upper oesophageal sphincter
. aspiration of liquid and paste bolus pre and post swallow
. a virtually complete right pharyngeal hemiparesis
. a reasonably strong cough which is effective in clearing some of the
aspirate from the trachea

Several strategies and manoeuvres were attempted during the videofluoroscopy.
Use of a right head turn in combination with the Mendlesohn manoeuvre was
shown to be most effective in prolonging the opening of the upper sphincter
however these did not eliminate aspiration. T has been advised to utilise
these strategies when attempting to take any oral intake. In addition T has
been issued with exercises which may improve back of tongue movement and
opening of the upper sphincter. It would be useful also to consider pressure
studies of the upper sphincter and possibly the lower sphincter as well as T
reports regular and severe acid reflux. Depending on the outcome of these
studies I wonder if it would be worth considering as a next stage Botox
injection into the upper sphincter with the final consideration of
cricopharyngeal myotomy.

In addition we arranged for T to have a more detailed analysis of speech with
one of our colleagues and it was decided that for the next few weeks T would
focus exclusively on the swallow exercises. May I suggest that we review T
jointly in the voice clinic and evaluate progress with exercises and decide at
that point whether it would be appropriate to give some further work on
speech.

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Speech & Language Therapy Advice   2001

Dear T

Further to your consultation with Speech & Language Therapy please find below
a list of the recommendations that were discussed with you. We hope you find
these useful and look forward to seeing you again when you are reviewed.

Recommendations

When attempting to swallow you should :
1. Turn your head as far round to the right hand side as possible.
2. Attempt to keep your Adam's apple in its highest position for 2-3 seconds
longer in order to prolong the opening of the top of the gullet.
3. Carry out on an intensive basis the exercises for the base of your tongue
and the top of your gullet that were given to you on the day.
4. Favour liquids but if trying any thicker consistencies alternate swallows
with small sips of water.

Paula Leslie
Degree Programme Director
Surgical and Reproductive Sciences
Faculty of Medical Sciences
University of Newcastle
Newcastle upon Tyne
NE2 4HH
UK
T +44 (0) 191 222 6279
F +44 (0) 191 222 8988
http://www.ncl.ac.uk/sars/postgrad/MSc.htm