Getting Started WELCOME. Multiple Lessons Interactive Exercises References Related Resources CEU Test

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1 WELCOME 2008, American Speech-Language-Hearing Association Getting Started Multiple Lessons Interactive Exercises References Related Resources CEU Test

2 PRESENTER PANEL Provides information about the presenter. NAVIGATION PANEL Access content by clicking on topics, or by title search. TOOLBAR Access relevant resources, references, and links; or exit the program. CONTENT PANEL Displays slides, movies, simulations, and videos. PLAYBACK CONTROLS Adjust volume, play or pause the program, jump to the previous or next slide. NOTES BUTTON Access program transcript (when available). Access CEU Test at CEU Tips: 1. Print test question PDF from attachments. 2. Complete test in its entirety. 3. Refer to program content. 4. You have three attempts to achieve 80%. 5. Notice of completion sent upon successful completion of test. 6. CEUs are recorded automatically for members of ASHA CE Registry.

3 ASHA-Approved Approved CE Provider: ASHA Professional Development is approved by ASHA's Continuing Education Board to provide continuing education activities in speech-language pathology and audiology. This self-study study is offered for X.X ASHA CEUs (XX level, XX area). ASHA Continuing Education Provider approval does not imply endorsement of course content, specific products, or clinical procedures. Decision Making in Adult Dysphagia: Assessment to Management Gary H. McCullough, PhD, CCC-SLP Associate Professor Speech Language Pathology Department University of Central Arkansas

4 Description Patients with multidimensional problems require more than one approach to assessment, and often more than one profession. Inter- and intraprofessional agreement is a daunting challenge. Focus on swallowing problems that require more than meets the eye. Learning Outcomes You will be able to: identify key issues related to intra- and interjudge agreement for swallowing assessment choose appropriate measures from the various tools of our trade to gain a more global perspective on swallowing problems provide a supportive environment to the interdisciplinary team needed to provide optimum care for patients with dysphagia choose appropriate management options for patients with dysphagia, including referrals and follow-up

5 Decision Making in Adult Dysphagia: Assessment to Management Introduction Comprehensive Evaluation History Chart ChartReview Basic BasicOral Oral Mechanism Exam Exam Oral Oral motor motorfunctioning Cranial Cranial nerve nervetesting Assessment Assessment of of functional functional swallow swallow

6 Available Assessment Tools Direct Visualization Videofluoroscopy Nasoendoscopy Indirect Observations Clinical/Bedside Exam Assessing Swallowing in Clinical Setting Utilize many different tools solidify knowledge of anatomy and physiology acquire an appreciation for the depth and breadth of this challenging mechanism

7 Management and Treatment Overall Support Assessment Quality of Life Medical Nutritional Growing a Decision Tree Lesson 1: Nature and Nurture Lesson 2: Building Strong Roots Lesson 3: Leaning on All Limbs Lesson 4: Clinical Case Studies

8 Program Emphasis Clinical exams, including nasoendoscopy and videofluoroscopy Incorporating findings of each assessment tool into a global patient picture, including medical, nutritional, and quality of life concerns Clinical cases where diagnosis and management require more than one tool and more than one professional Clinical team approach Lesson 1 : Nature and Nurture Medical Concerns Nutritional Concerns Quality of Life Concerns

9 Decision Trees Growing a decision tree is like growing any other kind of tree it requires knowledge (assessment tools and team member roles), following guidelines (research and clinical data), constant care (follow-up and discussion), and if all else fails seekingseeking more advice (referrals). Swallowing Evaluation Concerns Medical Quality of Life Nutritional

10 Medical Concerns Best indicator of outcomes: Overall health status prior to problem Overall health status during an event Aspiration and Pneumonia Aspiration is complex Aspiration pneumonia can be caused by treatment for dysphagia

11 Research Aspiration pneumonia is: 7.6x more likely in aspirators than non-aspirators 5.6x more likely in aspirators of thick liquid/solid than thin liquid Death 9.2x more likely in aspirators of thick liquid/solids than aspirators of thin liquid (Schmidt et al., 1994) Culprits in the Development of Aspiration Pneumonia Dependency for oral care Number of decayed teeth Number of medications Necessity of tube feeding Dependency for feeding Smoking Multiple medical diagnoses Requires suctioning Chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), or other high risk medical diagnosis Weight loss Urinary tract infection Bedbound Decreased alertness (Langmore, 1998)

12 Colonization Aspiration Complications Reduced pulmonary clearance Compromised immune system Role of Mechanism Bacteria in mouth and stomach can be aspirated and make person sick Reduced saliva can increase oral bacteria Dehydration, tube feeding, and bad oral care can influence oral health Some meds such as antacids and even tube feeds can influence stomach bacteria (Langmore, 1999)

13 Medical Etiologies Neurologic disease Gastrointestinal disease Pulmonary disease Diabetes Post surgery or other reason for intensive care placement Impact of Aging General Neurologic Increase in periventricular white matter hyperintensities Decrease in overall number of nerve cells Thirty percent decline in speed of action potentials between the 20th and 80th years of life Swallow Specific Decreased sensation for smell and taste Changes in laryngopharyngeal sensation Slower passage of the bolus through the oropharynx Slower transitions between stages of swallowing (i.e., oral to pharyngeal, pharyngeal to esophageal)

14 Swallowing Exam Examples Videofluoroscopic of 24-year-old and 84-year-old swallowing thin liquid, solid consistency, and multiple thin liquids from a cup Think About 1. Rate of movement of bolus through oropharynx 2. Initiation and magnitude of structure movements 3. Whether residue from the boluses remains in the oropharynx

15 Videofluoroscopic Swallowing Examination 1 The following swallows: 1. Thin liquid 2. Solid consistency 3. Multiple thin liquids from a cup 24-year-old individual Videofluoroscopic Swallowing Examination 2 The following swallows: 1. Thin liquid 2. Solid Consistency 3. Thin liquids from a cup 84-year-old individual

16 Think about. Conclusion 1. Rate of movement of bolus through the oropharynx Bolus moves much more slowly through the oropharynx in the older adult 2. Initiation and magnitude of structure movements 3. Whether residue from the boluses remains in the oropharynx Movements of structures shorter and delayed in the older adult Residue from the boluses remain in the oropharynx Nutritional Concerns More Medical Problems Complexity Medical Problems Nutritional Problems

17 Type II-striated oral-pharyngeal muscle fibers are highly susceptible to protein-energy malnutrition (PEM) causing a potential decline in swallow function. More Medical Problems Complexity Weight Loss and Dehydration Neurologic and muscular function changes associated with aging may decrease the amount of oral intake Medical Problem Nutritional Problems Dehydration, malnutrition and weight loss can increase neurological and muscular dysfunction, and negatively affect swallowing Typical Aging Swallow Remains functional in the absence of disease (stroke, heart attack, cancer) Highly susceptible system, so unrelated medical conditions and hospitalizations can dramatically affect swallowing Consider and address medical and nutritional concerns 50% of the institutionalized elderly suffer from PEM and 30-60% are dysphagic

18 Registered Dietitian Role Nutritional risk input Consider lab values and factors Important to SLP Albumin (or pre-albumin) Total iron binding capacity (TIBC) (Elmstahl et al., 1999) Albumin Primarily made in liver Helps carry medicines and other substances through the blood Essential for tissue growth and healing Normal values for adults between 3.5 and 5.5 g/dl May be high when severe hydration occurs May be low with malnutrition Takes up to 21 days to measure

19 Prealbumin Used as a clinical indicator of nutritional risk Normal levels are greater than 170 mg/l Levels less than 100 mg/l may be considered a severe risk for nutritional compromise Measured in 2 days Useful to identify patients at risk quickly, allowing health care provider to provide nutritional intervention as soon as possible Total Iron Binding Capacity (TIBC) Measures level of iron in the blood (too much or too little) Commonly used as a test for anemia Normal values between 240 and 450 cc/dl Lower than normal levels can be indicative of nutritional compromise

20 Meal Consumption Patients should eat at least 60-70% of each meal Team of dietitian, speech pathologist, patient, and family members Find the root cause Determine possible solutions to improve food and liquid intake Quality of Life Wide array of concerns Increased time to consume a meal Increased fear associated with eating Compromise in pleasure of eating

21 SWAL-QOL McHorney et al. (2002) developed a comprehensive assessment Well-validated psychometrically Easily and reliably administered Incorporating Quality of Life Include patient and family Management options Decision-making process Ensure medical safety Ensure adequate nutritional intake Risks and benefits of eating for pleasure

22 Lesson 2: Building Strong Roots The Tools Interjudge and Intrajudge Agreement Sensitivity and Specificity Building Strong Roots Making good decisions requires Use of assessment tools and review of related research Understanding strengths and weakness of tools Knowledge of reliable judgments of tools Remember: Strong roots (assessment tools) and soil rich in nutrients (research knowledge) are needed to grow a decision tree!

23 More to Assessment Than Aspiration Aspiration should not be beginning and end of story for assessment and treatment Look at history, medical, and nutritional context Determine physiology of patient s swallow The Tools Clinical Swallowing Examination (CSE) Nasoendoscopic swallow examination, often referred to as Fiberoptic Endoscopic Examination of Swallowing (FEES ) Videofluoroscopic swallowing examination (VFSE)

24 Clinical Swallowing Examination (CSE) Most widely employed (McCullough, 1999) Often used clinically as a screening tool for aspirators Many publications aimed at detecting aspiration in patients Daniels, Brailey, Priestly, Harrington, Weisberg, & Foundas, 1998 Logemann, Veis, & Colangelo, 1999 Martino, Pron, & Diamant, 2000 McCullough, Wertz, & Rosenbek, 2001a Rosenbek, McCullough & Wertz, 2004 Observed for forsigns signsof of dysphagia Provides answers to to probing questions: How Howlong longdoes doesitit take take patient patienttoto eat eata meal? meal? Does Doespatient patientsit situp upat at 90 90degrees to toeat? How Howmany manyswallows does doesitit take takepatient patienttoto get getfood fooddown? down? What Whattypes typesof offoods foods does doesthe thepatient believe believeare aredifficult? Trial Trial Swallows Historical and and Medical Information Gathering Core Core Components of of CSE Dependency for fororal oralcare Dependency for forfeeding feeding Number of ofmedications Decreased alertness Medical stability, including neurologic and andphysical functioning Overall Overallnutritional status status and andlab labvalues Nutritional risk risk Quality Qualityof oflife Oral, Motor, Voice Voice & Cranial Nerve Assessment

25 Research No investigations for use of comprehensive CSE in characterizing patient in terms of medical status, nutritional status, and quality of life No research on CSE s utility for examining the functional aspects of feeding Consider Vocal quality Timeliness of swallow Completeness of swallow Number of swallows

26 Clinical Swallowing Exam (CSE) What Happened? Voice change an indication of material infiltrating the laryngeal mechanism Pharyngeal weakness and/or residue in the pharynx is difficult to clear

27 Nasoendoscopic Swallow Examination Often referred to as Fiberoptic Endoscopic Examination of Swallowing (FEES ) Use of a flexible, fiberoptic laryngoscope, passed trans-nasally, to examine the pharynx before and after the pharyngeal phase of swallowing (Langmore, Schatz, & Olsen, 1988) Research flourishing Protocol Food dyed either green or blue? Dye dilemma (Leder, Acton, Lisitano, & Murray, 2005) No radiation Duration of meal Topical anesthesia Note: Recently published article (Suiter & Moorhead, 2007) has demonstrated no physiological effect of the nasoendoscope on swallow physiology

28 Protocol Patient swallows food and/or liquid Clinician views bolus as enters pharynx and infers certain aspects of swallow physiology from the presence or absence of pharyngeal residue and/or aspiration Air pulse stimulators can be added to the scope to provide the ability to test for decreased pharyngeal sensation (Aviv, Kim, Sacco, Laplan, Goodhart et al., 1998) FEES Limitations Inability to directly visualize swallow Inferences are required Can see symptoms of dysphagia, but difficult to determine physiologic cause (Colodny, 2000; Leder & Karas, 2000; Leder, Sasaki, & Burrell, 1998) Complexity Decreased risk of pneumonia when using nasoendoscopy, as opposed to videofluoroscopy, for the swallowing evaluation (Aviv, 2000) Important to view results with caution Must look at the whole story of a patient

29 Nasoendoscopic Swallow Examination Swallow of blue dyed apple sauce Bolus entering pharynx, followed by period of white out Delay in onset of swallows helpful for viewing the structures as coated with blue milk Nasoendoscopic Swallow Examination

30 What Happened?... Obvious delay in onset Obvious residue after the second bolus is administered What happens during the swallow must be inferred Residue in inpharynx post swallow is isprobable indication of ofpharyngeal weakness of ofsome type Delayed initiation of ofswallow often result of of some type of ofneurologic disruption to tomuscles associated with swallowing Videofluoroscopic Swallowing Examination (VFSE) Gold Standard? Follow bolus from mouth to stomach Detect abnormalities of bolus flow and its biomechanical causes at any stage in process (Martin-Harris, Logemann, McMahon, Schleicher, & Sandidge, 2000)

31 Research Define sensitivity and specificity of other assessment tools and measures Determine appropriate management techniques and evaluate effectiveness Improve outcomes in diet and medical or nutritional status McCullough et al., 2001; Daniels et al., 1998 Elmstahl et al., 1999; Lazarus, 2000; Logemann, Pauloski, Rademaker, Cook, Graner, Milianti et al., 1992; Rosenbek, Roecker, Wood, & Robbins, 1996 Crary, 1995; Huckabee, & Cannito, 1999; Mann, Hankey, & Cameron, 1999 Limitations of VFSE Two-dimensional imaging Necessity for radiation exposure Unnatural form of swallowing evaluation posture and feeding are controlled barium is swallowed instead of food or liquid Instrumentation limited to use in medical facilities with fully-staffed radiology departments Imaging to quantify amounts of residue or aspiration Causes use of inferences in evaluation

32 Consider Swallow bolus of barium All aspects of oral and pharyngeal swallow can be viewed in lateral plan Video timer for measuring timeliness of swallow VFSE

33 Reliability Careful examination of potential uses and problems of each tool Data aids in choice of tool Reliability of measures is important Inter- and intrajudge reliability Reliable Measures 1. Must be consistent 2. Consistency with yourself and with other raters across a short period of time

34 Reliability and Agreement Reliability Reported with a statistic Kappa for binomial judgments Pearson s correlation for numeric judgments Use sample sizes Agreement Reported in interms of of percent Doesn t account for sample size Reliable Measures For Assessment CSE Presence of ofdysphagia FEES Patient aspirates Patientaspirates 8 point Penetration/Aspiration scale Spillage Pharyngeal Residue VFSE Patient aspirates 8 point Penetration/Aspiration scale Duration measures Residue at atall allstages Other biomechanical impairments at atall allstages

35 Reliability of Judgment: CSE Half of all measures rated with adequate intrajudge reliability Less than half rated reliably across clinicians Most reliable interjudge rating for overall presence or absence of dysphagia Difficult to agree on specifics of dysphagia (McCullough et al., 2000) Reliability of Judgment: FEES Increasing visualization of the swallow would improve reliability is not entirely true Nasoendoscopy reported 80% intrajudge agreement, and 70% interjudge agreement rating for penetration/aspiration Colodny, 2002

36 Reliability of Judgment: VFSE Interjudge reliability for detecting aspiration is good (Kuhlemeier, Yates, & Palmer, 1998; McCullough, Wertz, Rosenbek, Mills, Webb, & Ross, 2001; Scott, Perry, & Bench, 1998) Seeing the passage of the bolus through the oropharynx adds little to the reliability of dysphagia assessment beyond ratings of aspiration Reliability of Judgment: VFSE Reliability increases in small groups trained to criterion on specific ratings for VFSE (Scott et al., 1998) Bolus viscosity may have an impact on reliability Ratings made with thick liquid, puree, or solid consistencies tend to be more reliable that ratings made with thin liquid (McCullough et al., 2001; Scott et al., 1998)

37 Intra- vs. Inter- Intrajudge reliability is much improved over interjudge reliability Measures of oropharyngeal residue, epiglottic function, and cricopharyngeal function were all made with significant intrajudge reliability in one study (McCullough et al., 2001) Least Reliable Judgments Everything except aspiration Reliability poor across the board, with varying degrees of impoverishment with type of rating Lip closure, jaw movement, and lingual function have been rated with better reliability on CSE and VFSE than on measures involving deeper structures Structures that move quickly and have few data regarding normal appearance during swallowing, such as the epiglottis and the hyoid bone, are rated much less reliably than other functions

38 Summary Interjudge ratings might be reliable; but don t count on it Ratings made with thicker consistencies tend to be more reliable than thin consistencies Structures that move quickly and have limited data regarding normal function are less reliable Aspiration is rated with strong intra- and interjudge reliability with nasoendoscopy and videofluoroscopy Most measures, clinical and instrumental, require training to criteria to rate reliably with others Determine Useful Results 2x2 table (Rosenbek, McCullough, & Wertz, 2004) Compare measure to a gold standard Tally the numbers of true and false positives and true and false negatives

39 Aspiration on VFSE Positive Negative Row Sums Positive Wetvoice a/tp b/fp c/fn d/tn Negative Column Sums N Aspiration on VFSE Sensitivity = a/(a + c) = 11/( ) = 50% Specificity = d/(b + d) = 24/( ) = 63% Positive Predictive Value = a/(a + b) = 44% Negative Predictive Value = d/(c + d) = 69% Positive Likelihood Ratio = sensitivity/(1 specificity) =.50/(1 -.63) = 1.4 Negative Likelihood Ratio = (1 sensitivity)/specificity = 0.8 C/B E = clinical/bedside examination VFSE = videofluoroscopic swallowing examination TP = true positive; FP = false positive; FN = false negative; TN = true negative (McCullough et al., 2001)

40 Sensitivity and Specificity in Detecting Aspiration Reliability rating is high compared to other data ratings Data is modest and variable Silent aspiration Occur in approximately 40% of all neurologic patients who aspirate (Logemann, 1998; Splaingard, Hutchins, Sulton, & Chauduri., 1988) Clinical Signs Abnormal cough Absent gag-pharynx Dysphonia Dysarthria Cough after swallow Voice change after swallow Reduced laryngeal elevation Multiple swallows per bolus Difficulty managing secretions Failure of 3 ounce swallow test

41 Biomechanical/Physiologic Aspects of Swallowing Oral bolus contain Bolus prep/mastic Lingual motility Initiation of swallow Soft palate elevation Tongue base retraction Hyolaryngeal excursion Pharyngeal contraction Laryngeal closure P-E segment opening Sensation CSE Research Few data support CSE as a detector of biomechanical or physiologic swallowing impairment Most focus on penetration or aspiration Most supportive evidence loosely related to actual evaluation of swallowing

42 CSE Research Patients successfully characterized as having oral dysphagia 69% of the time pharyngeal swallow delay 72% of the time pharyngeal dysphagia 70% of the time (Logemann et al., 1999) Research on VFSE Address biomechanical and temporal aspects of swallowing Han, Paik, & Park, 2001; Lazarus et al., 2000; Logemann, Williams, Rademaker, Pauloski, Lazarus & Cook, 2005; Perlman, Booth, & Grayhack, 1994; Perlman, VanDaele, & Otterbacher, 1995

43 Research on VFSE Relationship to aspiration Perlman et al., 1994 Management and treatment options Logemann et al., 1992 Martin-Harris at al., 2000 Sorin, Somers, Austin, & Bester, 1988 Outcomes Aviv, 2000 Logemann et al., 1992 Research on FEES /FEESST Highlight tools ability to detect penetration or aspiration, residue, and laryngopharyngeal sensory deficits Relationship types of judgments between FEES/FEESST and VFSE about 50% when tallied together (Tabaee, Johnson, Gartner, Kalwerisky, Desloge, & Stewart, 2006) No direct comparisons reported for defining the physiology, or biomechanics, of swallowing between VFSE and FEES/FEEST

44 Treatment Focus Proposed that treatment of dysphagia should focus on swallow physiology/specific biomechanical breakdowns rather than on symptoms, such as aspiration (Huckabee & Pelletier, 1999) Limited research examining dietary recommendations made from CSE in relation to recommendations from VFSE support that proposition Sensitivity and specificity are not reported for diet and treatment recommendations VFSE and CSE Agreement between CSE and VFSE on diet and treatment recommendations has been reported as low as 35% (Splaingard et al., 1988) A combined approach to assessment, incorporating both VFSE and CSE, has been proposed (Ott, Hodge, Pikna, Chen, & Gelfand, 1996)

45 Compare In terms of diet and treatment recommendations based on swallow physiology, should FEES be limited when compared to VFSE Aviv (2000) addresses recommendations regarding feeding and treatment Lesson 3 : Leaning On All Limbs Overview Incorporating CSE Measures Into VFSE and FEES Clinical Decision Making Down the Road

46 Leaning On All Limbs Choosing the best assessment tool(s) is critical! Do not rely exclusively on one form of assessment! Remember: You would not put all your weight on one tree limb because it ss likely to break! Overview Ideal World CSE, FEES, VFSE Gain valuable information Real World CSE and FEES CSE and VFSE Incorporate certain aspects of ofcse into FEES or orvfse

47 Incorporate CSE into VFSE or FEES CSE Measures Retrieve outcome data on onaspiration pneumonia risk factors History includes dependency for oral care, or ornumber of of decayed teeth VFSE and FEES Measures Very brief history Assessments of of cranial nerve and oral motor function are brief or ornon- existent Swallow Physiology VFSE All Physiologic Variables (11) VFSE Initiates Swallow CSE CSE Anterior oral bolus containment Bolus prep/mastication Lingual motility Gross hyolaryn excursion FEES FEES Posterior oral bolus containment Soft Palate Laryngeal Closure Sensation

48 Determining Function and Risk Factors Best determined by skilled CSE If not able or willing to perform CSE, then broaden scope of VFSE and FEES Comprehensive history Oral motor assessment Ascertain additional information in terms of function for inpatients as part of treatment Inadequacies FEES Only 5 out of 11 physiologic variables can be observed Cannot address concerns related to oral or pharyngeal stage function Cannot observe aspiration during a swallow Poor on function and sensation Patient must aspirate and cough during exam to see function and sensation Less dense tissue is not always visible benign growths cancer VFSE

49 When To Incorporate More Than One Instrumental Exam Disruptions to bolus flow are evident Patient complains of dysphagia, but no signs of oral-pharyngeal dysfunction are observed When the test results do not make sense, consider another tool, or even a referral! Examining and Altering Outcomes Follow-up Instrumental Exam Continued Patient Prosperity Treatment

50 Clinical Decision Making En-Suite Aspiration Overall medical condition Cognition Oral hygiene Ability to care for self Greater risk for pneumonia Decision Flow Chart

51 Clinical Decision Making Follow up in 3-6 months If risks are high do not wait for a formal evaluation Instrumentation can be used in treatment Monitor success Make adjustments CSE Measurement in Treatment Goal examples Patients will demonstrate use of the chin tuck in three consecutive sessions without coughing Patient will perform Mendelsohn maneuver with 90% success, utilizing 4-finger method of laryngeal palpation to monitor success

52 Instrumentation Measures in Treatment Serial FEES (Leder, 1998) Teach and monitor success with compensatory strategies Chin tuck, head turn, Mendelsohn maneuver, etc. Adjust treatment goals as necessary Summary Consider nature and nurture Management decisions must be ongoing Incorporate as many tools as are available Ensure medical safety, good nutritional status, and best possible quality of life

53 Lesson 4 : Clinical Case Studies Case Study 1 - Tom Case Study 2 - Betty Case Studies More than one tool and one individual are often needed!

54 Case Study 1: Tom 71-year-old male Odynophagia (pain when swallowing) especially on solids, increasing over a period of 1 to 2 months During Clinical Swallowing Exam swelling just below the right angle of the mandible Positive for Horner s syndrome: pinpoint pupil, lowered eyelid, and reduced tear duct production Remote history of CVA with no reported difficulty swallowing at that time

55 Lateral View 1. Thin liquid 2. Thin liquid 3. Nectar thick liquid 4. Honey thick liquid 5. Puree 6. Puree Anterior-Posterior View 1. Puree 2. Puree and right head turn VFSE

56 Developing Appropriate Management Option Medical Positive for history of CVA but not for dysphagia related to the CVA Horner s syndrome is present but creates no real concerns regarding swallowing No history of aspiration pneumonia and no other medical conditions that would place this patient at high risk Cares for himself in all areas and maintains good oral hygiene Nutritional Has lost some weight but is able to eat soft foods and liquids Problems are getting worse and starting to affect ability to take oral nourishment Quality of Life Able to eat many of the foods he enjoys Suffers pain when swallowing Situation limits his ability to function socially and reduces pleasure

57 FEES 1. Thin liquid 2. Nectar liquid

58 What Happened to Tom? ENT diagnosed pseudoaneursym that mimicks pharyngeal cancer Right carotid artery resected and reconstructed

59 Key Points Symptoms observed on VFSE did not match up well with the history Took a different look with nasoendoscopic view of a pseudoaneursym Consulted closely with other health care provider Otolaryngologist Constantinides, Passant, & Waddell, Similar case where pseudoaneurysm mimicked a parapharyngeal abcess. Remember: When symptoms and histories don t coordinate well, it is best to exhaust available tools and consult closely with other health care providers. Case Study 2: Betty 82-year-old female Hypertension Remote CVA (40 years prior) with no reported dysphagia Peripheral neuropathy Osteoporosis Chronic obstructive pulmonary disease History of partial thyroidectomy for thyroid nodule Reports dysphagia mainly with pills; dysphagia began roughly 3 years earlier Slightly decreased lip and tongue strength on left side and hoarse/ gravelly voice Referral from her geriatrician to SLP for videofluoroscopic swallowing (VFSE) examination

60 Lateral View 1. 5 ml thin liquid 2. 5 ml thin liquid 3. 5 ml thin liquid 4. Puree 5. Puree 6. Solid 7. Cup liquid VFSE

61 Developing Appropriate Management Option Medical Positive history of CVA Recent history of thyroid nodule with partial thyroidectomy within the past year Swallowing uncomfortable for 3 years but no ostensible problems medically Nutritional Maintained weight for the past six months and eats most things Reports difficulty with pills and some solids Quality of Life Not dramatically affected Item of Note Radiology resident scanned patient s chest to observe for signs of stricture. Discovered a pacemaker not found in the medical record.

62 VFSE Lateral View 10 ml thin liquid PA View 10 ml thin liquid

63 Key Points Many speech pathologists would stick to the physician request and focus on the pharyngeal swallow and potential problems surrounding thyroid tissue. Consider what you are and are not seeing and the outcomes. Betty has no occurrences of weight loss, dehydration, or pneumonia. Would it have mattered if the esophageal dysphagia remained undiagnosed? Primary care physician has not referred Betty for further evaluation so esophageal problem remains untreated.

64 Closing Fact: Increase in susceptibility to protein-energy malnutrition, and other complications related to swallowing, increases in the 80-and-over age population. Results: Multiple medical problems begin to collect and collide, making outcomes not always obvious or even reported. Remember: As a speech pathologist, the best bet is to be as thorough as you can, document what you see, and give the patient and the referring physician as much information as you can to keep the patient heading forward rather than backward with his/her medical care. Thank You! Michele Lash Instructional Designer/Program Manager Janet Brown, MA, CCC-SLP Content Coordinator/Speech-Language Pathology Parrish Swann Instructional Technology Manager Matthew Cutter Managing Editor Ghazala Osman Peer Review/Pilot Test Manager 2008, American Speech-Language-Hearing Association

65 CEU Test Link You will need your ASHA website login and password to access the test If you encounter any problems contact