[Dysphagia] Chronic Dysphagia Laryngospasm

[speech at wcgh.org (Michael Towey)]

We have an interesting and unusual case recently evaluated and need some
help.
 
47 y/o female nurse. Chronic (25 year) HX of dysphagia, difficulty
getting food down, she chews and chews, difficultly initiating swallow,
when she swallows, the 'food stops and gets stuck." She notes pill
dysphagia as a child. 
 
Also, she has had laryngospasm about 1 X per month, primarily related to
swallowing,  for many years, she just 'relaxes' and it goes away.
Recalls onset of laryngospasm 25 years ago waking at night with a
laryngospasm prior to her marriage. Never been worked up, but no other
HX of any disease, illness. 
 
Apparently healthy woman with nothing in her medical history. Working
regularly as nurse. She denies any hx of  physical/sexual abuse.
 
Recently, increase in frequency and severity laryngospasm, she feels
like there is a "splash of saliva" that triggers it. 
 
Laryngospasms have increased, most related to eating, patient is clear
she feels s 'splash of secretion" prior to the onset
 
Presently, she is unable to eat, just cannot complete swallow. May take
1-2 hours to eat serving of yogurt.  No other history, no meds. 
 
Has not been worked up by neuro or by GI. 
 
Swallow study with FEES IDs normal pharyngeal/laryngeal function, with
delayed initiation of swallow - mild premature spillage that stays in
vallecular prior to swallow. We did catch a laryngospasm during
endoscopy - she had been instructed in a management technique of the
laryngospasm prior to the FEES and was able to very effectively manage
the episode. Laryngeal mucosa looks OK. No laryngeal  irregularities,
VFs look pretty,  no edema, no erythema, well hydrated, no  throat
clearing, no dysphonia. 
 
There is a suspicious collection of white, thicker secretions that
appeared to arise from subglottic area  during a swallow/cough
(difficult to be fully certain due to obliteration of view during
swallow), that then seems to stay in the interarytenoid space and area
of UES. Very hard to tell if this is a reflux event. 
 
A MBS was done at another facility, identified 'premature spillage" but
exam was not recorded. Reflux symptoms are negative (no throat clearing,
no dysphonia, no c/o excessive secretions, no VF tissue changes). Reflux
Symptom Index negative.
 
Her swallow characterized by excessively long oral preparation,
effortful swallow initiation, the  feeling of the 'swallow stopping and
food getting stuck'. Reflexive swallow of secretions is occasionally
effortful, often WNL. No dysarthria, oral motility wnl.
 
After FEES, she was able to complete a number of very successful
swallows with instruction; left feeling very positive, then problem
progressed.
 
She has lost 15-20 lbs in last year due to decreased p/o intake (not a
large woman to begin with), 14 additional lbs in last couple of weeks
and  is giving herself fluid IVs. Feeling desperate (both of us!).
 
She is HIGHLY anxious, distraught, fearful. She repeatedly says the
anxiety is an overarching concern. Referred for psych consult, on
Klonopin  (two weeks), no apparent effect.
 
Her MD reports lab values re: nutrition look fine although she is self
administering fluid IVs. And here's an interesting image to give to a
patient. When she voiced deep concerns about her nutrition, her MD
assured her she was fine, reminding her that "concentration camp
survivors went months without food." Needless to say, that didn't lend a
real boost to her confidence about this problem,
 
Yesterday  she  received a PEG. It was very painful for her, meds did
not diminish her anxiety or comfort level. A few stomach polyps were
noted and the GI doc noted "No esophageal peristalsis during the
endoscopy."
 
Here's what we've doing/recommending to her MDs: 1. Consider 2 X day
PPI. Symptoms at least in part suspicious for reflux related event. 2.
Seek counseling for management of anxiety and any other related psych
needs. 3. Repeat  MBS to get complete exam of oral pharyngeal and
esophageal function. 4. Neuro, GI consults.4. RX consists of working to
increase speed of initiation of swallow reflex, thermal stim,
progressively tighten/relax oral structures. Anterior-posterior, attempt
maintain laryngeal elevation during swallow, try different bolus sizes.
Get back to more automatic, sequential  swallow (anxiety is really in
the way.) 
 
This lady very discouraged, anxious and feels helpless and unsuccessful.

 
I know psych hx and chronicity are powerful negative prognostic
indicators -however, this is a young, productive patient.
 
What are we missing here?  Anyone have any suggestions? Any thoughts on
electrical stim?
 
 
Michael Towey, CCC-SLP
Voice & Swallowing Center of Maine
Belfast, Maine 
207-338-9349