[Dysphagia] polio and critical illness neuropathy

[pressmah at sjhmc.org (pressmah@sjhmc.org)]

First, as to the frothy mouth I would suggest that this is an indication of
reflux and that a trial of a PPI might be helpful.  As to the issue of
Polio, Barbara Sonies did an article a number of years ago on Dysphagia and
Post Polio Syndrome.  You might be able to find it on medline
www.nlm.nih.gov.  It seems likely that he has been compensating for
swallowing problems secondary to post polio syndrome and has now
decompensated due to his other medical problems.  He may not be able to get
back to baseline but I would think that a three month trial of treatment
would be indicated.  Hilda Pressman

-----Original Message-----
From: Henry, Anna [mailto:AHenry@mncahs.health.nsw.gov.au]
Sent: Tuesday, October 11, 2005 8:37 PM
To: 'dysphagia@b9.com'
Subject: [Dysphagia] polio and critical illness neuropathy


Hi,

I wonder if anyone can suggest a direction for treatment. I have a few ideas
but all opinions on management would be welcome.

My client is a 79 yr old man with a history of dysphagia from polio at 22yrs
of age. An MBS done prior to his admission to a Sydney hospital for a heart
surgery showed weakness on the oral and pharyngeal stages of the swallow
that he has lived with for many years, but he had never had aspiration
problems, and this was shown on MBS.

Early this year he went Sydney for heart surgery and for various reasons
suffered a bad aspiration pneumonia thought to be from aspirating perhaps
some food leftovers in his mouth during the surgery. He had a respiratory
and I think also a cardiac arrest during his course of recovery. It was a
difficult course of recovery, he lost about 5 kilos and was healthy but a
lean build prior. 

I knew him as an outpatient prior to this. He had come for a review of his
swallow and I found no aspiration. He has significant hypernasality from
adenoidectomy at 6 yrs of age also. His voice was otherwise of near normal
quality at that time.

Since the surgery/recovery course, he was admitted to the rehab ward of the
hospital I work at. We trialled a few weeks of exercises for improving his
laryngeal elevation and closure but this was somewhat hampered by his asthma
and sleep apnoea which resolved he says at home once away from air
conditioning. Lack of sleep during rehab didn't help swallow progress.
An MBS showed that although, as I thought at the bedside, he was getting
better laryngeal elevation and was better able to initiate a swallow, he now
had NO sensation of laryngeal entry of thin or thick liquids or puree and
aspirated all regardless of double swallow, with huff or cough to command as
we had practiced etc.

The rehab specialist feels he is suffering a critical illness neuropathy
from his difficult course after surgery so that the polio residual problems
as well have left him on PEJ bolus feeds only. Also, that recovery from this
neuropathy could be, usually a 12 month period, but given his polio
background and perhaps also his age (his soft palate closes during
swallowing re the adenoidectomy) it may be longer than this.

He is coughing frothy white (?aspirated saliva) still, as he did since
return to here from Sydney/surgery, and still is, having been home for 2
months now. He sounds a little gurgly and can clear this but does so more
intentionally than reflexively, so I feel his laryngeal sensation is quite
reduced still though a little improved re sensing build-up on his cords as
it wakes him a few times a night now.

My plan is to continue conditioning exercises and monitor indicators of
return of sensation. The rehab med staff checked his chest for infection at
my request re the white frothy cough-ups and found no infection. With little
experience of polio sufferers particularly, I'd be grateful for any thoughts
about management of this (lovely) man. MBS during rehab, done 3 months ago
now, showed that his 'cough' occurred after aspiration up to a minute later
- totally ineffective.

He is definitely staying NBM at home as he is quite afraid of another
pneumonia as he had a nasty experience of this post-surgically, needing
resuscitation from respiratory arrest.

Thanks for any input,

Anna

Anna M Henry
Adult Speech Pathologist,
Coffs Harbour Health Campus
Locked Bag 812
Coffs Harbour 2450
Ph: 02 6656 7605
F:   02 6656 7687