[Dysphagia] Severe pharyngeal dysphagia

[DRolfe at nsccahs.health.nsw.gov.au (Deanna Rolfe)]

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Hi Everyone,

I'm new to this listserv, so forgive me if this topic has already been discussed.

I am seeing a patient in acute care who has severe pharyngeal dysphagia.
MBS today showed generally intact oral stage...with only mildly reduced base of tongue movement.
He attempted to initiate the swallow at the base of tongue...to describe what I saw - no anterior hyoid movement/laryngeal elevation or tilt, no epiglottic inversion, no airway closure, bolus (puree) was not pushed through the pharynx, but stuck to base of tongue, valleculae and posterior pharyngeal wall, and underside of epiglottis after 2nd swallow. Multiple swallows did nothing to aid clearance. It was like the pharynx was closing around the bolus and not moving it anywhere. (I'm trying to describe visually so people don't have to guess what my terminology means!)
Nectar consistency was slightly better (due to its runnier nature)...but similar happened as with puree, however some reached the pyriforms between the swallows, and multiple swallows were a little more effective (but only a little bit). Penetration into the laryngeal vestibule was seen, but cleared with a cough (on command).
Thin fluids were no better, and this time aspiration occurred between the swallows during multiple swallows to clear the residue. Coughing was elicited, but only cleared some...not all.

This man is 86 years old...has no medical reason why swallowing difficulties should be happening (neurological investigations have come back with nothing significant)...he had 2 toes amputated at a private hospital...complications occurred and he ended up with a trache...now removed and healed...was transferred to a rehab facility...and then to our acute hospital with respiratory symptoms ++++. He hadn't seen a SP at the 2 hospitals previous to ours, but obviously had difficulties, as nurses at the 1st hospital put him on thickened fluids!

This man is cognitively intact, and motivated to eat again...he is currently NBM with NG feeds.
He is an ideal candidate for therapy.
Other than Shaker exercises, what would others suggest I try???
(no strategies or techniques seemd to help during MBS)
Any suggestions would be greatly appreciated!

Deanna
Australia


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