Adults With Dysphagia Case Studies · • Integrate a medical history and diagnostic information...

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Interactive Problem-Solving

Michael Groher, PhD, F-ASHA, Honors ASHA

Adults With Dysphagia Case Studies


• Financial: I receive royalties from publications through Elsevier and from my courses on MedBridge

• Nonfinancial: None to disclose

Disclosures


• Apply the most relevant aspects from a medical history related to the patient’s dysphagia complaint

• Formulate a diagnostic hypothesis based on the clinical and laboratory data

• Utilize a more organized approach to how one makes step-by-step clinical decisions

• Integrate a medical history and diagnostic information into a treatment plan

Learning Goals


Chapter 1Case Number One: Food Seems to Stick in My

Throat


Case Number One: “Food Seems to Stick in the Back of My Throat”

A 46-year-old female with a past history of well-controlled rheumatoid arthritis is referred from her primary care physician because of increased difficulty swallowing solid food in the past three months. Her major complaint is that food sticks in the back of her throat, making it difficult to finish a meal. She is worried that the problem has not gone away and is getting worse.


Additional Information• Confirm that her problem is only for

solids. If liquids also are problematic, it might suggest a severe obstruction, or neurologic disease if associated with coughing.

• Does she cough when eating solids? If yes, it may suggest that material from a possible obstruction is falling into the airway.

• Has she lost any weight? Unintentional weight loss is often a signal of severity

• Has she changed her dietary habits? For instance, now is avoiding solids, which might confirm her symptoms.


Additional Information (cont.)• Has she experienced any changes in

muscle strength in any part of her body? If yes, it might raise the suspicion of undiagnosed neurologic disease.

• Has she experienced any voice changes? Rheumatoid arthritis may affect vocal function and, by implication, protection of the upper airway, or interactions between the coordination of breathing and swallowing.

• Does she complain of reflux (pain or regurgitation)? If so, she could be referring her symptoms to the neck when, in fact, the problem is below that level.


Her Reply

• She denied weight loss, problems with choking on any material, and any changes in muscle strength or voice

• She admitted to occasional heartburn that she thought was more frequent as her swallowing difficulty has worsened

• The examiners then administered a screening of mental status and an oral peripheral swallowing examination. Both were normal.


VF Study

The patient underwent a modified barium swallow study in the standing position. This test was chosen as it can easily view the oral, pharyngeal, and cervical esophageal stages of swallow. She was given thin barium in 10 cc and 20 cc amounts. Then she was given 10 cc of liquid of a honey-thick consistency (denoted by the numeral 2 on the study).


VideoSticking One


VideoSticking One: Revisited


• The video does confirm that thicker material does not easily clear the UES

• There is residual bolus above the UES and in the vallecular space

• Potential etiologies– Since hyoid elevation is normal, the restriction to flow is

not related to loss of mechanical traction– The patient could have had a small brain stem infarct that

has resulted in failure of the UES to fully relax

Possible Etiologies


• She could have a localized obstruction within the UES (such as a web) that was not visualized on this study

• She could have a localized myositis (poly- or dermato-) since these can be associated with other connective tissue disorders, one of which she already has

• There could be an underlying esophageal disorder that is affecting UES mechanics

Other Possible Etiologies


Since the patient was standing for her study, it was easy for the radiologist to scan the esophagus. She was given a mouthful of a pudding-thick bolus and was instructed to swallow it once. This part of the study is on the next slide.

Pathway Selected


VideoSticking Two


Video Interpretation

• There was almost total lack of esophageal motility

• Some material appeared to retropulse back to the level of the UES, suggesting possible LES dysfunction not readily seen on this single swallow


• Her primary problem appears to be esophageal, not pharyngeal based

• Due to poor esophageal motility, pressure mechanics throughout the alimentary tract are abnormal, affecting flow not only in the body of the esophagus, but through the UES, where the patient senses the problem

• The patient may have a primary motor disorder affecting the esophagus that would explain her complaint and perhaps her increasing GERD

• Since she has a history of connective tissue disease, the dysmotility may be secondary to scleroderma as part of overlap syndrome

Differential Diagnosis


Next Steps

• Return her to her rheumatologist for confirmation of and/or treatment of scleroderma or other connective tissue disorders with your report of her swallowing study

• Suggest to the rheumatologist that the patient may benefit from a full radiographic evaluation of esophageal function (per the radiologist)

• If GERD is confirmed, involve the gastroenterologist


Additional Interventions

• The SLP recommended that the patient try to maintain her nutrition using thin liquids

• Involve the dietitian for counseling on high-protein liquid diets and preparation suggestion for nonsolid materials

• Counseling aimed toward shorter, more frequent meals

• Counseling about the future use of a feeding tube


• When hyoid bone movement is normal and there is obvious residual bolus above the UES, suspect a disorder either within the UES or below it

• Although rare, suspect a connective tissue disorder as an etiology that affects the esophagus in patients (especially women) who already have the diagnosis of a connective tissue disorder that may not affect swallow function

Summary


Chapter 2Case Number Two: I Can’t Seem to Swallow

My Vitamins


Case Number Two: “I Can’t Seem to Swallow My Vitamins”

A 46-year-old male complained to his primary care physician he had increasing difficulty swallowing his vitamins. It has been increasingly worse in the last six months to the point that he does not try to swallow them because they stick somewhere. He denies any changes in neurologic status and is in general good health. He is employed, with a family of four.


Important Elements From the History

• The problem is progressive and seems to be getting worse

• He is not sure where they seem to stick

• He is young and presumably in good health

• His only focus seems to be on vitamins


• Many people report that swallowing their pills is problematic

• Pill swallowing may involve a separate neurologic circuity since we concentrate on how to swallow them as opposed to regular food items

• He reveals that swallowing his larger vitamin pills seems to be the issue and denies any other solid food problems

• He denies any periods of GERD that may delay esophageal motility and make swallowing of larger materials more difficult

Useful Additional Information


VF Study Was Ordered

He underwent a VF study with a 13 mm pill in the lateral and AP planes. He then was asked to swallow a large amount of thin barium in an attempt to dislodge the pill.


VideoVitamins 1


• The pill was lodged in the piriform sinus• The patient was then imaged in the AP projection,

wherein the pill was seen to lodge in the right piriform sinus

• He was then given a mouthful of thin barium in an effort to dislodge the pill and viewed in the AP plane

VF Result


VideoVitamins 2


• There is considerable collection of barium in the piriform sinuses

• The liquid barium appeared to clear the 13 mm pill from the right piriform sinus on the second swallow

• There is a major abnormality of bolus flow through the region of the UES. There appears to be a stenosis with a dilated (bulging effect) above it. It is unclear if this stenosis is within the cricopharyngeal region or in the cervical esophagus.

• There is an abnormality of bolus flow in the esophagus below the level of the stenosis

VF Interpretation


VideoVitamins 2: Revisited


Endoscopic Result

A swallow endoscopy was performed in the clinic. As part of this routine exam, the patient was asked to perform a Valsalva maneuver to evaluate pharyngeal function. A large vascular lesion appeared to arise from the left piriform sinus that reached the level of the true vocal folds.


VideoVitamins 3


• The patient was referred to GI, who did an endoscopic study

• They identified two polypoid lesions, one at T1, the other at T8. A biopsy was consistent with a benign intraluminal fibrovascular polyp.

• GI consulted the thoracic surgeon. They decided not to excise the lesion at the mid-esophageal level but opted to excise the more superior lesion because of the threat to the upper airway. It was excised, and the swallowing complaint subsided.

Referral to GI


• Relatively benign complaints about swallowing difficulty should be taken seriously

• The combination of endoscopy of swallow and videofluoroscopy often is useful in finding the underlying cause of a swallowing complaint

Summary


Chapter 3Case Number Three: Easy to Miss the Problem


Case Number Three: Easy to Miss the Problem

A 64-year-old male had tongue base cancer five years ago and was treated with a full course of radiation. During the treatment, he had some swallowing complaints but ate a regular diet without any weight loss. Now he complains of increasing intermittent difficulty with solids and occasional problem with liquids causing some choking episodes. He returned to his ENT, who ruled out any recurrence and ordered an MBS. At the ENT, his physical exam was normal except for minor xerostomia.


VF Study

The patient underwent a VF study, first swallowing normal amounts of a thickened barium, followed by a thicker pudding bolus. Video images were first taken in the lateral projection, and then AP images were taken.


VideoTongue Base Cancer


VideoTongue Base Cancer: Revisited


• Patients with the diagnosis of a web often complain of intermittent difficulty

• Webs are difficult to view on modified barium swallow studies unless the studies are reviewed in slow motion

• Webs are easily managed with standard dilatation

Summary


Chapter 4Case Number Four: Constant Cough with

Bronchitis


Case Number Four: Constant Cough With a Diagnosis of Bronchitis

A 90-year-old female is brought to the outpatient radiology clinic for a VF swallowing study because of increasing choking episodes while eating. She lives alone and is accompanied by her daughter who reports she has been having these choking episodes for at least a year. The patient’s daughter took her to their primary care doctor, who diagnosed her problem as bronchitis and put her on antibiotic therapy. After multiple courses of antibiotic therapy over the past six months, her coughing episodes continue.


VF Study

The VF study was completed while she was standing, first in the lateral plane with normal amounts of thin barium and then in the lateral plane with the same material


Video90-Year-Old Lateral View


Video90-Year-Old Lateral View: Revisited


Video90-Year-Old AP View


Video90-Year-Old AP View: Revisited


• There appears to be a marked deviation of the cervical esophagus to the left

• Below the level of the heart, there is a deviation to the right

• Abnormal “dripping” was thought to be barium that leaked from the patient’s mouth and did not represent a fistula

VF Interpretation


• A chest CT was recommended by the radiologist. It revealed a large tumor extending from the right lung field. A subsequent biopsy revealed a malignant small cell carcinoma.

• After the patient’s biopsy, the daughter returned to ask if her mother could continue to eat, and what might be the best course considering her current diagnosis

Next Step


• She returned for a VF study that showed minor aspiration on materials such as yogurt and thinned pudding

• She was opposed to thickening her liquids• She was not willing to have any type of a feeding tube

placed

• She continued to eat orally until she succumbed to her disease two months later

Final Outcome


• In the elderly, bronchitis may be diagnosed for what actually might be an aspiration-related pneumonia

• The primary etiology for an obvious pharyngeal abnormality also requires inspection of the esophagus to make sure the esophageal disorder is not the primary cause

• The SLP should be prepared to help patients make decisions about the use of a feeding tube, even in the circumstance of obvious, potentially life-threatening consequences

Summary


Question and Answer Session

Adults with Dysphagia Case Studies: Interactive Problem Solving

1

Bibliography

MedBridge Adults with Dysphagia Case Studies: Interactive Problem Solving

Michael Groher, PhD, F-ASHA, Honors ASHA

1. Andreoli and Carpenter (2018) Cecil’s Essential’s of Medicine, 9th edition. Chapter on Connective Tissue Disorders.

2. Levine, MS (1996) Fibrovascular polyps of the esophagus: clinical, radiologic, and pathologic findings in 16 patients. Am J Roentgenol, 781-87.

3. Ozcelik, C et al. (2004). Fibrovascular polyp of the esophagus: diagnostic dilemma. Interactive Cardiovasc Thoracic Surg 260-262.

4. Jones, Bronwyn (2016) Normal and Abnormal Swallowing, 2nd edition. Section on webs. 5. Groher M, Crary M (2019) Dysphagia Management in Children and Adults, 3rd edition.

Chapter 6: section on Pharyngoesophageal Relations. 6. Shatto B, Erwin K. (2016) Moving on from millennials: preparing for generation Z. J

Contin Educ Nurs. 47: 253-4. 7. Humbert I.A. (2015, June 3). Critical thinking in dysphagia management [web log post].

Retrieved from http://dysphagiacafe.com/2015/06/03/critical-thinking-in-dysphagia-management/

8. Rowles J et al. (2013) Faculty perceptions of critical thinking at a health sciences university. J Scholarship Teaching and Learning. 13: 21-35.

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