[Dysphagia] recommendations requested

[nszklane at macneal.com (Szklanecki, Nicole)]

Hi Julie,
Would you mind posting the information for the course you teach? I just ran into a case similar to Keri's today, and I'd definitely like to learn more about esophageal issues.
Thanks!
Nicole 

-----Original Message-----
From: dysphagia-bounces@b9.com [mailto:dysphagia-bounces@b9.com]On
Behalf Of Julie Speech
Sent: Friday, September 08, 2006 3:57 PM
To: Dysphagia@b9.com; Keri Vasquez
Subject: Re: [Dysphagia] recommendations requested


Hi Keri,

This patient's dysphagia would appear primarily esophageal with 
oropharyngeal symptoms (i.e. he aspirates as a result).  It is not likely 
acute (probably age related and came on gradually would be my guess-- but 
also may be related to reflux).  The results of the esophagram are 
consistent with his complaints- tertiary contractions- especially 
"extensive" means spasm of the esophagus, non-propulsive. This would 
certainly give you solid food dysphagia, occasional trouble with liquids, 
regurgitate at times and would likely make you aspirate when the esophagus 
doesn't clear.  In layman's terms- if the pipes get backed up down below 
(the esophagus), the bolus remains in the pharynx and is more likely to be 
aspirated.  I am not sure what is meant by "exaggerated contraction of the 
UES" but I would think that means hypertension of the cricopharyngeus which 
is also descriptive of the "cricopharyngeal prominence".  This often comes 
first and will end up creating a Zenker's as this is an area of weakness. 
This leads to increased compliance through the UES and makes more of the 
bolus remain in the pharynx.  For CP hypertension, he may benefit from 
management of this, including reflux modifications or medical management, 
Botox or dilatation of this area if he were a candidate.  In any case, he 
certainly has more than one issue here that would be consistent with his 
subjective complaints.

While he may be at risk for aspiration given his esophageal dysphagia, 
thickened liquids are a mistake.  Esophageal clearance will be worse.  Keep 
in mind that the VFSS is supposed to identify the physiology behind why the 
person is having trouble, not just what consistency he aspirated.  I would 
bet that given the amount of residual he had with thicker consistency, he 
would eventually aspirate this as well.  Aside from a GI consult to question 
the above (a general referral for GI is not as helpful as questioning some 
of the things I mentioned above), I would consider-
- Warm fluids with meals (i.e. warm decaf tea or warm water) avoiding cold 
as this decreases spasm and increases esophageal clearance
- Reflux diet and precautions as well as aspiration precautions
- Pharyngeal exercise program- may as well beef up the pharyngeal 
musculature in hopes of compensating for the deficits below
- aggressive oral care
- soft diet with thin liquids, water being best choice, avoiding tough, 
fibrous solids
-  may help to crush pills, but need lots of water to follow to make sure 
they clear the esophagus- not to add localized esophageal injury to his list

I tend to think you have enough to go on with both the studies you 
mentioned, even if the VFSS wasn't as complete as perhaps it could have 
been.
Sorry for the lengthy response, I am passionate about this topic and have 
been for years.  That is why I have self-educated in regard to esophageal 
issues and their effect on all aspects of swallowing.  Thank goodness the 
patient refused NPO status.  We owe it to our patients to know this stuff 
and not negatively impact their quality of life with our recommendations. 
Kudos to you for looking further into the situation on behalf of your 
patient!  If you are interested, I teach a 2 day course on the topic and 
would be happy to pass on the information!  Good luck!  :o)  Julie

----- Original Message ----- 
From: "Keri Vasquez" <kvasquez21@yahoo.com>
To: <dysphagia@b9.com>
Sent: Friday, September 08, 2006 11:29 AM
Subject: [Dysphagia] recommendations requested


> To all the gurus:
>
>  New admit to my sub-acute facility, 86 yo male who was hospitalized w/ 
> chief complaint of progressive dysphagia over 3 weeks( solids >liquids). 
> Pt had subjective complaints of "food getting stuck and coughing food up."
>
>  During hospitalization pt had VFSS and esophogram.
>
>  Report for the VFSS:
>  Pt. only given nectar and honey thick barium w/ aspiration of nectar and 
> ineffective cough.  Chin tuck does not prevent aspiration.  With honey 
> thick barium, pt has mod residue in vall. and piriform that is partially 
> cleared w/subsequent swallows but no evidence of laryngeal pen/asp.  There 
> is cricopharyngeal prominence.
>
>  Report for esophogram:
>  There is exaggerated contraction of the UES w/ adjacent small 
> outpouching, likely representing a Zenkers.  There is a lack of normal 
> esophageal peristalsis w/extensive tertiary contractions.  Contrast flows 
> into the stomach without any evidence of obstruction.
>
>  This pt. was recommended NPO by the hospital SLP in which he refused.  He 
> was admitted here on a puree diet and honey-thick consistency.  Pt. 
> refused EGD.  KUB was negative.  Pt denies any relfux symptoms and is 
> currently taking pepcid.
>
>  1. What should I do with this patient?  I feel the VFSS is incomplete and 
> lacks appropriate information.  Uncertain why no swallow maneuvers were 
> introduced and the drastic conclusion to make this pt NPO.
>  We have the mobile VFSS available and contemplating to have a repeat 
> study to obtain a full and complete report.
>
>  Any comments/suggestions are greatly appreciated!
>
>  Keri Miloro, MS, CCC-SLP
>  Boston, MA
>
>
>
> __________________________________________________
> Do You Yahoo!?
> Tired of spam?  Yahoo! Mail has the best spam protection around
> http://mail.yahoo.com
> _______________________________________________
> Dysphagia mailing list
> Dysphagia@b9.com
> http://lists.b9.com/mailman/listinfo/dysphagia 

_______________________________________________
Dysphagia mailing list
Dysphagia@b9.com
http://lists.b9.com/mailman/listinfo/dysphagia


This message (including any attachments) is confidential and intended solely for the use of the individual or entity to whom it is addressed, and is protected by law. If you are not the intended recipient, please delete the message (including any attachments) and notify the originator that you received the message in error. Any disclosure, copying, or distribution of this message, or the taking of any action based on it, is strictly prohibited. Any views expressed in this message are those of the individual sender, except where the sender specifies and with authority, states them to be the views of
MacNeal Health Network.
This footer also confirms that this email message has been scanned for the presence of computer
viruses.