[Dysphagia] Dysphagia Management suggestions

[colleenkerr at optusnet.com.au (Colleen Kerr)]

Hello all - I would welcome some fresh input into this case:
78 yo now three months post acute onset severe dysphagia post cholycystectomy and repair choledocodudenal fistula. Hx septic shock, bilat carotid disease, IHD, Ca bladder and Ca palate (local excision 4 yrs prior leaving small fistula). Mild pre-existing dysphagia (no specific details) associated with fistula but pt had maintained weight with some texture modifications only. MBS at acute hosp suggested severe impairment at all levels - tongue pumping, reduced base of tongue, premature spillage, delayed swallow onset, severely reduced laryngeal elevation, reduced epiglottic inversion, penetration on all consistencies, aspiration on thin, inadequate UES opening, slow oesophageal clearance. Continued NBM/NGT (Pt refuses PEG). This gentleman has been in rehab for two months, incredibly motivated with Dysphagia therapy - Mendhelson's, Shakers, Base of Tongue and Effortful Swallow. No access to E-stim. He has made minimal gains - swallow onset faster, some improvement in laryngeal elevation, max 60 mls cold puree on oral trials. Oral secretions still thick/stringy - completing dry mouth care regime and oral suctioning. Discharged home for OP review - both patient and GE refuse PEG. I have requested neuro work-up (given acute onset looked like lateral medullary syndrome) but no findings on MRI/CT - for Neurology review next week. Hopefully for repeat MBS in next few weeks. Any thoughts re new therapy direction/further investigations/management of secretions would be very much appreciated. Thankyou
Colleen

Colleen Kerr
Speech Pathology
20 Morrison Pce., Pennant Hills 2120
ph. 0403 903 822