[Dysphagia] Brain stem tumor and dysphagia

[bonnieh4455 at sbcglobal.net (Bonnie Heintskill)]

I have a new patient with a brainstem glioma. I did an assessment on him today as he has a PEG tube due to little to no epiglottal inversion. Laryngeal elevation is very limited too during eval today using very small pieces of ice chips.  Respiratory support for prolonged Ah is 20+ seconds. His articulation has been affected with hypernasality noted. He can't get the abdominal muscles to engage to help him cough and clear, except when he aspirates his own saliva but even then there is not much activity.  Even using tactile assistance does not help.  He suctions himself at night.  His whole right side is affected with weakness, has lost the hearing totally in the right ear, he has allodynia in his face and is on neurontin for the nerve pain. Pain is 5/10 constantly, even with the neurontin. He is w/c bound now.  He said he used to get the hiccups frequently before started PEG tube feedings. He has had 2 MBSS in hospital and "flunked" both of them (his words).  Spouse reported that the food was being aspirated straight into his lungs and the radiologist stopped the MBSS immediately. I don't have copies of the MBSS reports. I am seeing him for homecare. He recently under went radiation therapy in several places and had oral medication chemo  too.

Medications he is on:
Decadron 8mg BID
Amytriptyline 75 MG at bed time (for sleep and relaxing muscles)
Ritalin 30 mig every a.m. (patient/spouse want to discharge this med as he is alert)
Gabapentin 300 MG 3x/day

He has started using a wedge pillow in bed which has stopped his night coughing from reflux.

He has also started oral medication chemotherapy (Temodar - higher dose than previously) and Zofran for nausea. His MD has hope for him that the new round of higher dose chemo will help him.

His goal is to eat mashed potatoes by Thanksgiving.  Voice is wet and gurgly 75% of the time during the evaluation.

Has anyone worked with a patient like this? What is the prognosis for regaining any swallowing function or should he just have some oral/gustatory satisfaction?  Will doing miminal strengthening exercises/ROM exercises be beneficial for him?

Is there anything the MD can add for medications to keep secretions thin so he can manage them better? Is this even a viable option with his aspiration risks?

Thanks.
Bonnie Heintskill, MS, CCC/SLP


Any suggestions would be appreciated.