[Dysphagia] Fear of Choking

[smberlinger at mindspring.com (susan berlinger)]

Would appreciate any input. Sorry for the lengthy HX.

 

Just received an interesting referral for a 12 year old male. About 1 ? years ago, he had a choking episode while eating a PB&J and macaroni & cheese. He reported that he is afraid to eat because he thinks he is going to choke again and feels the sensation of a lump in the throat. His mother is concerned about her son maintaining his nutrition as he has eliminated many foods from his diet and has lost weight over the last year. The patient is comfortable drinking water and eating only pureed consistency. He avoids solids, puree with pieces and will not eat any sandwiches. His mother believes that family illnesses, hospitalizations, and treatment contribute to her son?s fears of choking. He was referred for a videofluoroscopic swallow. There was no evidence of aspiration or penetration. There were apparent compensatory features secondary to fear of choking. Rule out esophageal dysmotility, GERD, Dysphagia. .  He presents with asthma-prescribed Albuterol.

 

Prior to his choking episode, he ate all foods. All aspects of his posture WNL for safe eating, lingual and labial movements WNL with the exception of limited upper lip movement, rounding and some unusual deliberately slow, awkward lingual movements when eating which appear to be secondary to his fear of choking. He demonstrated good soft palatal movement during an intra-oral examination and presented with a Class 1 (neutrocclusion).  He consumed the following consistencies and foods during the assessment: water, nectar, tomato juice, pudding, apple sauce, PB & J, and a cookie wafer. He tolerated all foods and consistencies well. It was observed that his hand shook when he would grasp for a cup of liquid. On approximately 3 occasions, he displayed a light cough and cleared his throat immediately following.  He reported that on a few occasions he felt something stuck in his throat while drinking. He took small bites of the sandwich, manipulated it slowly within the oral cavity and swallowed with good laryngeal elevation. He took small bites of the wafer which dissolved quickly and he was comfortable taking additional bites. He was asked to chew gum and rotate it from side to side. He did this successfully. 

 

He is a great child. He was referred to our center by his psychiatrist because he was unfamiliar with how to proceed.  I want to make sure I am not missing anything. Appreciate you input

 

Methods of Feeding and plan

1.	Oral with recommendations, regular diet with restrictions and include family in all aspects of treatment
2.	Reduce maladaptive behaviors by developing understanding of normal swallowing, mastication and how the lip, tongue and teeth play a crucial part in bolus preparation for swallowing. Create a positive eating environment
3.	We talked about how the teeth rip solid food and changes to a puree-like consistency before swallow. To validate, he enjoys spitting out solid food after chewing. This will be acceptable for short period of time.  
4.	Develop improved lingual, labial movements and mastication 
5.	Patient to utilize ?chin tuck? position and/or other compensatory strategies to enhance safe swallow
6.	Avoid the following foods: Slippery Foods - (String beans, macaroni and cheese, corn, etc.)  
7.	He will continue to see psychiatrist and shares all of what we do in treatment. He is to give one anatomical structure dealing with eating to his psychiatrist to educate him
8.	We created a menu chart and note book. His goals are to identify quantity of food consumption weekly and at home. Each day he is required to eat more.
9.	We created a list of all foods he wants to eat.
10.	Promote quiet mealtime environment with supervision. Add new foods as needed. 
11.	Establish strong home program to increase carryover and facilitate improvement
12.	Consultation with patient, family, psychologist, and physician as needed

 

Thank you for your expertise and feedback


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