[Dysphagia] Epiglottic deflection and dysphagia

[KMilford at adhb.govt.nz (Kate Milford)]

Hi AnnaMaria
I have had a number of patients like this - who have no apparent cause
for the epiglottic movements problems. I know this can happen after
radiotherapy to the neck area. My working hypothesis is that the
cartilage has stiffened and therefore although it is pulled down to a
horizontal position it doesn't fold. I have discussed it with the ORL
consultants who are none the wiser! 
Maybe it is related to having had years of GORD?
I have only seen it in older people - age related changes in cartilage
structure?
It doesn't appear to have any neurological basis anyway. 
I don't know what can be done - and have not managed to improve the
epiglottic deflection in any of the patients I have seen. They do tend
to have significant dysphagia - as yet none are needing alternative
feeding but it can be a struggle for them to maintain their nutrition,
and all are on supplements. I advise avoiding any "sticky/cloggy" foods
and they tend to manage on soft casseroles/minced meats, with soft veg.
Bread, mashed potato etc are very difficult. Some report that crunchy,
dry foods are OK - and most have made changes to diet to compensate.
Kate


-----Original Message-----
From: dysphagia-bounces@b9.com [mailto:dysphagia-bounces@b9.com] On
Behalf Of AnnaMaria Koo
Sent: Thursday, 19 October 2006 07:46
To: dysphagia@b9.com
Subject: [Dysphagia] Epiglottic deflection and dysphagia


Hello All,

I recently completed an MBS on a an 86year gentleman who had suffered a
fall and hip fracture.  His PMHx is significant for CVA/TIAs in 2001
with no apparent residual effects.  He reports that he had first noticed
difficulties swallowing in 2000 (May-Oct).  He explained it as
difficulties swallowing solids and that he either regurgitated it or it
felt "stuck".  An MBS was completed in 2000 which showed mild
oropharyngeal dysphagia related to decreased tongue base movement,
slight delay in triggering the swallow and slightly reduced bolus
control.

I saw this patient in Aug/Sept2006 and conducted an oral motor exam and
clinical ax.  Oral motor exam showed nothing remarkable.  He reported
similiar issues with swallowing reoccuring while he was in acute care.

On the MBS, the mechanics of his swallow appear normal (i.e. timing of
swallow, good tongue base retraction).  However the epiglottis hardly
deflects, it mainly pushes towards the posterior pharyngeal wall.  As a
result the bolus is held in the valleculae.  He does a lot of throat
clearing during his multiple swallow attempts (x5-6 at times per bolus),
this results in the bolus regurtitating back into the oral cavity.  

The timing of the UES opening appears normal and there were no other
remarkable structural/physiological anomalies.

On a recent CT of the head, it mentions small ischemic changes but no
acute cortical changes/infarcts.

My questions ares: 
1) What accounts for the specific impairment of the epiglottic
deflection?

2)What can be done? Are there any compensatory strategies?  I trialed a
liquid wash to facilitate swallowing of solids, but this was only mildly
effective. And using a "hard swallow" did not promote further
deflection.

Anna Maria Koo
Speech-Language Pathologist
Specialized Geriatric Services & NRC
SJHC, Parkwood Site
ext.42205

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