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[Dysphagia] Dysphagia Digest, Vol 39, Issue 21
- Subject: [Dysphagia] Dysphagia Digest, Vol 39, Issue 21
- From: jk2 at cardinalhill.org (Jill Kobak)
- Date: Tue, 20 Feb 2007 07:20:44 -0500
Michael,
I worked with an experience SLP who specialized in voice and she taught me how to treat vocal cord dysfunction (laryngospasms/ vasovagelsyncope). She was trained at National Jewish Respiratory Hospital in Denver, CO where VCD was first caught on stroboscopy and named. We know all of these things but this is how she explains this to the patients in a way that they understood. She tells them that the primary function of the vocal cords is protection of the airway and not vocalizing. They are made of muscle and therefore have muscle memory. Once they get in to a hyperprotective mode which can be brought about by post nasal drip, GERD, LPR, odors, penetration/ aspiration, etc VCD can result. During a VCD episode the vocal cords try to close to protect the airway at inappropriate times resulting in feelings of tightness in the pharynx and can, in extreme cases, result in syncope. Anxiety plays a big part in this process and most patients that I have seen for this have an anxiety component. In some cases the patient is so scared of experiencing difficulty and anxious about this they can bring VCD about. I have never had a case as extreme as yours but this may help in that perhaps undertanding what might be going on and having a way to deal with it in a simple manner may decrease her anxieties. The treatment is simple. Teach her relaxed throat breathing or VCD release. The idea is to keep a stream of air passing through the vocal cords so they cannot close. She needs to take a gentle sip of air in through relaxed but slightly pursed lips for about 2 seconds and gently blow out for about 5 seconds. This should be a relaxed effort with her shoulders down using abdominal breathing. She should continue this pattern until the tightness in her throat is gone. She should practice this 5 times a day when she is not having symptoms so that it becomes automatic and she will know what to do immediately when she feels s/s of this. I know it seems that it may not be directly related to your patient but I feel it may be worth a try with her. You can also get on the National Jewish website to read more about VCD if you wish.
Good Luck!
Jill Kobak, MEd, CCC/SLP
Program Coordinator
Center for Outpatient Services
Cardinal Hill Rehabilitation Hospital
Lexington, KY 40504
jk2 at cardinalhill.org
-----Original Message-----
From: dysphagia-bounces at b9.com [mailto:dysphagia-bounces at b9.com]On
Behalf Of dysphagia-request at b9.com
Sent: Monday, February 19, 2007 6:21 PM
To: dysphagia at b9.com
Subject: Dysphagia Digest, Vol 39, Issue 21
Send Dysphagia mailing list submissions to
dysphagia at b9.com
To subscribe or unsubscribe via the World Wide Web, visit
http://lists.b9.com/mailman/listinfo/dysphagia
or, via email, send a message with subject or body 'help' to
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When replying, please edit your Subject line so it is more specific
than "Re: Contents of Dysphagia digest..."
Today's Topics:
1. Helga Schollenberger is out of the office.
(Helga Schollenberger/HDGH)
2. Re: Dysphagia Digest, Vol 39, Issue 20 (melissa zilberstein)
3. Re: Chronic dysphagia (Kate Milford)
4. Allergy to Barium (Walsh, Linda (R1SE))
5. Re: Chronic Dysphagia Laryngospasm (Vikki Stefans)
----------------------------------------------------------------------
Message: 1
Date: Mon, 19 Feb 2007 14:09:45 -0500
From: "Helga Schollenberger/HDGH" <HSchollenberger at hdgh.org>
Subject: [Dysphagia] Helga Schollenberger is out of the office.
To: dysphagia at b9.com
Message-ID:
<OF8DA71694.466C8508-ON85257287.0069435C-85257287.0069435C at private.hdgh.org>
Content-Type: text/plain; charset=US-ASCII
I will be out of the office starting Mon 02/19/2007 and will not return
until Mon 03/19/2007.
I will respond to your message when I return.
------------------------------
Message: 2
Date: Mon, 19 Feb 2007 15:08:28 -0500
From: "melissa zilberstein" <mzilberstein at msn.com>
Subject: Re: [Dysphagia] Dysphagia Digest, Vol 39, Issue 20
To: dysphagia at b9.com
Message-ID: <BAY129-F2815A3201B4DECB3A067BAC78A0 at phx.gbl>
Content-Type: text/plain; format=flowed
Has anyone considered MS in this equation?
Melissa Zilberstein
>From: dysphagia-request at b9.com
>Reply-To: dysphagia at b9.com
>To: dysphagia at b9.com
>Subject: Dysphagia Digest, Vol 39, Issue 20
>Date: Mon, 19 Feb 2007 12:00:01 -0700
>
>Send Dysphagia mailing list submissions to
> dysphagia at b9.com
>
>To subscribe or unsubscribe via the World Wide Web, visit
> http://lists.b9.com/mailman/listinfo/dysphagia
>or, via email, send a message with subject or body 'help' to
> dysphagia-request at b9.com
>
>You can reach the person managing the list at
> dysphagia-owner at b9.com
>
>When replying, please edit your Subject line so it is more specific
>than "Re: Contents of Dysphagia digest..."
>
>
>Today's Topics:
>
> 1. Re: Chronic Dysphagia Laryngospasm (Jai Gupta)
>
>
>----------------------------------------------------------------------
>
>Message: 1
>Date: Mon, 19 Feb 2007 09:17:31 +1100
>From: "Jai Gupta" <Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU>
>Subject: Re: [Dysphagia] Chronic Dysphagia Laryngospasm
>To: "Michael Towey" <speech at wcgh.org>, "Dysphagia List"
> <dysphagia at b9.com>
>Message-ID: <88EEDD02C11B6A4182DD21E42394DCFE127AAA at sesahs.nsw.gov.au>
>Content-Type: text/plain; charset=iso-8859-1
>
>
>Hi Michael,
>Looks like you have done all ...I had a similar case once from psychiatry
>....once they was treated for reactive depression by ECT she became
>perfectly normal after that and symptoms of dysphagia never returned. Ask
>you Psychiatrist what he think?
>
>
>
>
>Jai Gupta. M.Sc.(S.H.) CPSP MSPA
>Manager, Speech Pathology Department
>The Sutherland Hospital
>* Locked Bag 21, Taren Point NSW 2229 Australia
>* +612 9540 7111 page 594 or Direct +612 9540 7558
>*+612 9540 7717 *+61 0401 373 324
><mailto:Jai.Gupta@ sesiahs.health.nsw.gov.au>
>
>A Thought
>
>You see things; and you say, "Why?" But I dream things that never were; and
>I say, "Why not?" ...... George Bernard Shaw
>
>
>
>
>
>
>
>
>
>-----Original Message-----
>From: dysphagia-bounces at b9.com [mailto:dysphagia-bounces at b9.com]On
>Behalf Of Michael Towey
>Sent: Sunday, 18 February 2007 1:23 AM
>To: Dysphagia List
>Subject: [Dysphagia] Chronic Dysphagia Laryngospasm
>
>
>
>
>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
>
>_______________________________________________
>Dysphagia mail list: Normal and disordered swallowing information
>Dysphagia at b9.com
>Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
>Visit the new Dysphagia Web Forum: http://dysphagia.com/forum
>
>SOUTH EASTERN SYDNEY AND ILLAWARRA AREA HEALTH SERVICE CONFIDENTIALITY
>NOTICE
>
>NB: *** Due to an organisational amalgamation, email addresses for
>recipients in this organisation have changed. Please update your contacts
>list with the details of the email addresses contained within.
>
>This email, and the files transmitted with it, are confidential and
>intended solely for the use of the individual or entity to whom they are
>addressed. If you are not the intended recipient, you are not permitted to
>distribute or use this email or any of its attachments in any way. We also
>request that you advise the sender of the incorrect addressing.
>
>This email message has been virus-scanned. Although no computer viruses
>were detected, South Eastern Sydney and Illawarra Area Health Service
>accept no liability for any consequential damage resulting from email
>containing any computer viruses.
>
>
>
>------------------------------
>
>_______________________________________________
>Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
>Visit the new Dysphagia Web Forum: http://dysphagia.com/forum
>
>End of Dysphagia Digest, Vol 39, Issue 20
>*****************************************
------------------------------
Message: 3
Date: Tue, 20 Feb 2007 09:28:35 +1300
From: "Kate Milford" <KMilford at adhb.govt.nz>
Subject: Re: [Dysphagia] Chronic dysphagia
To: <dysphagia at b9.com>
Message-ID:
<CB37B770D06ADF4488F1F76C687E655608CD8E4D at Exchange03.adhb.govt.nz>
Content-Type: text/plain; charset="iso-8859-1"
Has she had a really thorough Gastro workup?
Could it be oesophageal achalasia?
Kate
________________________________
From: dysphagia-bounces at b9.com on behalf of melissa zilberstein
Sent: Tue 20/02/2007 9:08 a.m.
To: dysphagia at b9.com
Subject: Re: [Dysphagia] Dysphagia Digest, Vol 39, Issue 20
Has anyone considered MS in this equation?
Melissa Zilberstein
>From: dysphagia-request at b9.com
>Reply-To: dysphagia at b9.com
>To: dysphagia at b9.com
>Subject: Dysphagia Digest, Vol 39, Issue 20
>Date: Mon, 19 Feb 2007 12:00:01 -0700
>
>Send Dysphagia mailing list submissions to
> dysphagia at b9.com
>
>To subscribe or unsubscribe via the World Wide Web, visit
> http://lists.b9.com/mailman/listinfo/dysphagia
>or, via email, send a message with subject or body 'help' to
> dysphagia-request at b9.com
>
>You can reach the person managing the list at
> dysphagia-owner at b9.com
>
>When replying, please edit your Subject line so it is more specific
>than "Re: Contents of Dysphagia digest..."
>
>
>Today's Topics:
>
> 1. Re: Chronic Dysphagia Laryngospasm (Jai Gupta)
>
>
>----------------------------------------------------------------------
>
>Message: 1
>Date: Mon, 19 Feb 2007 09:17:31 +1100
>From: "Jai Gupta" <Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU>
>Subject: Re: [Dysphagia] Chronic Dysphagia Laryngospasm
>To: "Michael Towey" <speech at wcgh.org>, "Dysphagia List"
> <dysphagia at b9.com>
>Message-ID: <88EEDD02C11B6A4182DD21E42394DCFE127AAA at sesahs.nsw.gov.au>
>Content-Type: text/plain; charset=iso-8859-1
>
>
>Hi Michael,
>Looks like you have done all ...I had a similar case once from psychiatry
>....once they was treated for reactive depression by ECT she became
>perfectly normal after that and symptoms of dysphagia never returned. Ask
>you Psychiatrist what he think?
>
>
>
>
>Jai Gupta. M.Sc.(S.H.) CPSP MSPA
>Manager, Speech Pathology Department
>The Sutherland Hospital
>* Locked Bag 21, Taren Point NSW 2229 Australia
>* +612 9540 7111 page 594 or Direct +612 9540 7558
>*+612 9540 7717 *+61 0401 373 324
><mailto:Jai.Gupta@ sesiahs.health.nsw.gov.au <mailto:Jai.Gupta@ sesiahs.health.nsw.gov.au> >
>
>A Thought
>
>You see things; and you say, "Why?" But I dream things that never were; and
>I say, "Why not?" ...... George Bernard Shaw
>
>
>
>
>
>
>
>
>
>-----Original Message-----
>From: dysphagia-bounces at b9.com [mailto:dysphagia-bounces at b9.com]On
>Behalf Of Michael Towey
>Sent: Sunday, 18 February 2007 1:23 AM
>To: Dysphagia List
>Subject: [Dysphagia] Chronic Dysphagia Laryngospasm
>
>
>
>
>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
>
>_______________________________________________
>Dysphagia mail list: Normal and disordered swallowing information
>Dysphagia at b9.com
>Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
>Visit the new Dysphagia Web Forum: http://dysphagia.com/forum
>
>SOUTH EASTERN SYDNEY AND ILLAWARRA AREA HEALTH SERVICE CONFIDENTIALITY
>NOTICE
>
>NB: *** Due to an organisational amalgamation, email addresses for
>recipients in this organisation have changed. Please update your contacts
>list with the details of the email addresses contained within.
>
>This email, and the files transmitted with it, are confidential and
>intended solely for the use of the individual or entity to whom they are
>addressed. If you are not the intended recipient, you are not permitted to
>distribute or use this email or any of its attachments in any way. We also
>request that you advise the sender of the incorrect addressing.
>
>This email message has been virus-scanned. Although no computer viruses
>were detected, South Eastern Sydney and Illawarra Area Health Service
>accept no liability for any consequential damage resulting from email
>containing any computer viruses.
>
>
>
>------------------------------
>
>_______________________________________________
>Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
>Visit the new Dysphagia Web Forum: http://dysphagia.com/forum
>
>End of Dysphagia Digest, Vol 39, Issue 20
>*****************************************
_______________________________________________
Dysphagia mail list: Normal and disordered swallowing information
Dysphagia at b9.com
Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
Visit the new Dysphagia Web Forum: http://dysphagia.com/forum
------------------------------
Message: 4
Date: Mon, 19 Feb 2007 17:38:42 -0400
From: "Walsh, Linda \(R1SE\)" <LiWalsh at serha.ca>
Subject: [Dysphagia] Allergy to Barium
To: <dysphagia at b9.com>
Message-ID: <09957DD31ECEB94FAAD90F6D31FDD433B420DD at RHAEX1.RHA-RRS.CA>
Content-Type: text/plain; charset="utf-8"
Thanks to all who replied to my query about options for patients
allergic to barium. I forwarded your responses to my colleague who had
asked the question and he was most appreciative.
Linda
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Merci.
------------------------------
Message: 5
Date: Mon, 19 Feb 2007 17:38:39 -0600 (CST)
From: Vikki Stefans <vstefans at george.ach.uams.edu>
Subject: Re: [Dysphagia] Chronic Dysphagia Laryngospasm
To: Dysphagia List <dysphagia at b9.com>
Message-ID: <Pine.GSO.4.62.0702191729320.22274 at george.ach.uams.edu>
Content-Type: TEXT/PLAIN; charset=US-ASCII; format=flowed
WHAT????
where to start - first off, the splash of saliva and the mucousy stuff
which sounds like waterbrash, indicate reflux, and I'll tell you what, I
have learned not to care very much about how patients describe reflux
symptoms or even if they don't. Everyone experiences it very differently
apparently and if you require people to tell you they have heartburn and
sore throat before you treat, you will miss A LOT of people you can help
with an acid blocker.
A PEG tube seems like a pretty simple minded and potentially very poor
solution. Did they look at the esophagus on endoscopy or just the
stomanch? How about manometry or a pH probe first?
And KLONOPIN may be very good for some things but not as a first, second,
or even third line antianxiety med.
???
Vikki Stefans, M.D., pediatric physiatrist (rehab doc for kids) at UAMS
and Arkansas Children's Hospital. Working Mom of Sarah T. and Michael C.,
and wife of Henry Stefans. Every mom is a working mom!- OK, dads too.
On Sat, 17 Feb 2007, Michael Towey wrote:
>
>
> 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
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