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Communicating Optimal Treatments Identified on Videofluorography to Referral Sources Session Number: SC02 American Speech-Language-Hearing Convention Thursday, November 16, 2006 Loews Hotel Miami, Florida Answering the implied question Mary J. Bacon, M.A. CCC-SLP Rush University Medical Center Chicago, Illinois “Patient needs swallow study” The implied question Assist with diagnosis Patient information 81 year old gentleman Multiple pneumonias (three times in past year – none before that) Multiple medical problems Multiple medications (13) General diet No significant weight loss The implied question Is this gentleman getting pneumonias because he is aspirating food and/or liquid as he swallows? Additional history from patient “I don’t choke” Coughing noted past 10 months “I cough up mucus” “My coughing is not necessarily at mealtime” Vague answers to most questions Other observations Articulation wnl Voice quality and resonance wnl Hearing adequate with hearing aids Natural teeth; good oral hygiene 2 The fluorographic exam Included challenges with: patient-controlled cup drinking as well as food requiring mastication and thick pudding Oropharyngeal swallowing -functional Slight residue in mouth and/or pharynx, quickly cleared with spontaneous second swallow No aspiration No penetration The literature: People who aspirate foods and liquids may be more likely to get pneumonia (Martin, et al, 1994) People who aspirate (foods and) liquids do not always get pneumonia (Feinberg, et al, 1996) People who do not aspirate food or liquids get pneumonia (Kuru nd and Lynch in Respiratory Infections, 2 ed., Niederman, Sarosi and Glassroth (eds.), 2000) Rule in/Rule out No aspiration seen even with challenges of cup drinking and masticated food – not likely to be aspirating saliva on a regular basis No “close calls” (penetration) No threat of late aspiration due to oral or pharyngeal residue Appears to have good sensation Oral hygiene good No Zenker’s-type diverticulum Other possibilities Non G-I reason for pneumonias Aspiration of refluxed material 3 Further thoughts Pt’s med. list included Omeprozole though he denied ever having “heartburn” symptoms and was not sure why he was taking this drug No g-e reflux was incidentally noted during this exam What to report Results of this examination would suggest that prandial aspiration is not the likely cause of this pt’s pneumonias. The possibility that the pt may aspirate refluxed material is not ruled out by this exam. 4 Notes: 5 Using MBS to Communicate Changing Practice Patterns Joy Gaziano M.A. CCC-SLP, BRS-S H. Lee Moffitt Cancer Center and Research Center Tampa, Florida The Problem… Anecdotal observation revealed cases of dysphagia after thoracotomy. Occasionally this resulted in increased length of stay, increased utilization, need for non-oral nutrition, and poorer quality of life. Need further understanding of incidence and high risk populations. Need improved identification and treatment of dysphagia in this group. What is a thoracotomy? An incision to open the chest wall to access structures / organs in the thorax. For pulmonary resection a 3-6 in. incision is made– most common locations for incision: axillary, posterior, posteriolateral. The ribs are spread with a rib spreader. Through the incision a resection (segmentectomy), lobectomy, or a pneumonectomy is completed. Lung Resection Segmentectomy – (Wedge resection) Wedge-shaped section is removed. Lobectomy – The entire lobe of the lung is removed. Pneumonectomy – The entire lung is removed. 6 MBS Case Examples 69 yof had RLL resection for lung Ca. PMH: LRND with post-op XRT for SCCA, HTN. Xerostomia and dysphagia to pills, but reg. diet before surgery. Intermittent cough on liquid, puree and solids at bedside evaluation. Another example… 68 yom had left pneumonectomy for NSCLC. PMH: Prostate ca, CABGx4, CVA post CABG-cortical blindness. No previous dysphagia reported on reg. diet. Throat clear on liquids and purees, multiple swallows per bite, NC 02 on bedside evaluation. One more example… 72 yom had median sternotomy for mediastinal germ call tumor. PMH: Afib, GERD. No previous reported dysphagia on regular diet. Post op hoarseness, wet voice, no cough, decreased O2 sats, SOB at bedside swallow evaluation. View Videos Patterns Premature spillage to pharynx Laryngeal penetration/aspiration Reduced laryngeal sensation in response to penetrant/aspirant Pharyngeal residues Reduced esophageal motility 7 Retrospective Analysis Very low utilization of Speech Service by Thoracic Surgery Only 43% had documented resolution of dysphagia, usually within 30 days. Very poor outcomes compared to other populations treated by Speech department. Referred late in admission, not referred for follow-up after hospital discharge. There is limited data in literature and no data on population or outcomes at Moffitt to benchmark quality. Project Goals Identify patients with dysphagia post-thoracotomy. Prevent pulmonary problems related to aspiration in this population. Rehabilitate swallowing to allow return to oral intake. Identify risk factors for development of post-operative dysphagia. Corrective Action Changing Practice Patterns Based on findings: Each patient undergoing a thoracotomy was evaluated by the Speech Pathologist on post-op day one by clinical swallow eval. MBS if indicated. If no dysphagia, begin clear liquid diet and advance per post-op protocol. Ongoing therapy or short term monitoring for all patients by Speech Pathologist. Methods Demographic, operative and outcomes data were collected prospectively for patients undergoing thoracotomy and swallowing eval/tx from April until October 2005. (N=144 EVAL) Compared to data collected retrospectively from January 2004 until October 2004 with no swallowing eval. (N=152 HIST) 8 Results 18% had dysphagia on post-op day 1 or 2. Trends in deficits were seen on MBS –Delayed initiation of swallow –Laryngeal penetration/aspiration –Reduced sensation –Reduced esophageal motility Swallowing Outcomes 18% of patients evaluated had post-op swallowing problems. – 1/3 of abnormals had problems severe enough to warrant short term NPO. –1/3 required altered diet or specific aspiration precautions. – 94% of patients had complete return or functional swallowing with some limitations post treatment. (average 11 days, range 1-28 days) Functional Outcomes Two functional rating scales for swallowing were used: –ASHA FCM for Swallowing (0-7) –Royal Brisbane Hospital Outcome Measure for Swallowing (1-10) Pre- Post swallowing treatment outcomes: ASHA: 3.90—5.66 Brisbane: 5.4—6.83 Average Length of Stay Average Length of Stay (ALOS) –Historical: 10.4 days –Evaluation: 6.9 days 11 10 9 8 7 6 5 4 3 2 1 0 Historical Evaluation 9 12 11 10 9 8 7 6 5 4 3 2 1 0 Permanent Feeding Tubes Number of Permanent Feeding Tubes –Historical: 11 –Evaluation: 1 Historical Tracheostomies Number Tracheostomies –Historical: 9 –Evaluation: 2 10 9 8 7 6 5 4 3 2 1 0 Historical Pulmonary Complications Number of pulmonary complications –Historical: 10 –Evaluation: 3 Project Goals Revisited Evaluation Evaluation 10 9 8 7 6 5 4 3 2 1 0 Historical Evaluation Accurate and timely identification and treatment for patients with dysphagia post-thoracotomy. – Almost all patients were evaluated on post-op day one or when medically stable. Prevent pulmonary complications related to aspiration in this population. – Swallow assessment by Speech Pathologist is highly reliable in detecting aspiration. – Swallowing diet recommendations appear effective in preventing pulmonary complications. 10 Rehabilitate swallowing to allow eating by mouth Significant improvement in functional swallowing scores occurred after treatment. 94% of patients had return to normal or functional swallowing abilities after treatment. Identify risk factors for development of post-operative dysphagia. Possible risk factors include neurological disorders, CABG, reflux disease, or head and neck cancer. Patient age: 66.8 years (dysphagia) vs. 61.3 years (normal) Type of resection and site of surgery (pneumonectomy vs lobectomy; left vs right side) Additional Outcomes Standardized order process (clinical pathway) eliminates ambiguity, increases efficiency, and permits faster Speech Pathologist response time. Transition to designated Speech inpatient staff improves consistency, visibility, and staff satisfaction. Additional outcomes Certain high risk patients are regularly evaluated prior to surgery. – Five patients have been seen pre-op and had a post-op MBS– all had a decrease in swallowing function on post-op exam. –ASHA outcome score: o Average: 6 – decreased to 2.8 –Brisbane outcome score: o Average: 7.6 – decreased to 4.6 Additional Outcomes Patients discharged to home or SNF with persistent dysphagia are evaluated by SLP at the post-op clinic visit and provided with repeat evaluation / swallowing therapy as needed. 11 Unanticipated benefits Increased visibility in the Special Care Units has increased referral by other programs to our service. Patient satisfaction scores in the Speech department have improved on the floors where the Thoracic patients are treated. We have developed an excellent working relationship with Thoracic Surgery team. We have gained respect from Nursing staff in Special Care Units and have opportunities to share knowledge. Interesting Findings 33/62 patients exhibited esophageal stasis on initial videofluoroscopic exam. –? Impact of epidural ? –Impact of surgery on vagal function 5/62 patients had vocal fold paralysis following surgery, yet only 2/5 of those patients exhibited oropharyngeal dysphagia During Thoracotomy for Lung Resection Pt is intubated with a double lumen endotracheal tube. Future Directions Continue to evaluate and treat all patients and expand to other MDs. Evaluation of data for additional trends. Publish results! 12 Communication of MBS Results to Assist Medical Diagnosis Kristin Larsen, MA CCC-SLP Northwestern University Chicago Patient History 80 year old female “Word memory” difficulties Gradual progressive dysarthria Left temporal atrophy on MRI DDX: Primary Progressive Aphasia vs Frontal Lobe Dementia Swallowing Complaints Excess saliva Difficulty chewing, particularly foods such as lettuce Food sticking in throat Reports problems began 3-5 months prior Oral Motor Assessment Reduced lip closure Tongue deviation to right Mild lingual atrophy Mild lingual fasciculations Mildly hoarse voice, hypernasality Slow speech No language deficits noted in conversational speech MBS Results Reduced lateral tongue and jaw movement for chewing Slow oral transit times Delayed pharyngeal swallow trigger Incomplete closure of the larynx, resulting in penetration of liquids and aspiration on cup drinking Minimal residue in pharynx 13 MBS Interventions Chin tuck posture implemented Eliminated aspiration and penetration of liquids Recommendations from MBS Mechanical soft diet Chin down posture with liquids Suggested further testing to determine etiology of dysarthria and dysphagia Speech and swallowing picture more suggestive of motor neuron disease than PPA Referral Referred back to neurologist Additional testing completed Primary neurologist referred pt to Neuromuscular Disorder Clinic within the month Diagnosis of Bulbar Amyotrophic Lateral Sclerosis made ALS Clinic Follow Up Multidisciplinary approach –Motor Neuron Disease Neurologist –Pulmonologist –Home nurse liaison –Dietician –Speech Pathologist –Occupational or Physical Therapist Periodic Follow up (3-4 month intervals) 14 Symptom Progression - Speech Initial clinic visit: –Moderate dysarthria – Focus more on compensation than on active oral-motor exercises (Fowler, 2002) Within 2 months: –Loss of useful speech –Augmentative communication device Fowler, W., (2002) Role of Physical Activity and Exercise Training in Neuromuscular Diseases. American Journal of Physical Medicine and Rehabilitation. Vol. 81 (11) Symptom Progression - Swallowing Within 2 months: –PEG tube placed secondary to dehydration –Poor po intake –Continued intake of soft foods –Medications and most fluids via PEG tube Considerations for Non-oral Nutrition in ALS Aspiration Inefficiency Dehydration Malnutrition Worsening pulmonary status (percentage of predicted forced vital capacity can influence timing of PEG) 15 Notes: 16 Communicating Optimal Treatments: Post-surgical dysphagia managed during an inpatient stay Amy Baillies, MS, CCC-SLP University of Wisconsin Medical School Madison, Wisconsin Medical Presentation 87 year old female with papillary thyroid cancer Status-post total thyroidectomy Post-operative airway edema and need for re-intubation for airway obstruction Patient successfully extubated on post-operative day #3 ENT consult post-extubation due to airway issues ENT referral Findings of flexible nasoendoscopy on post-operative day #4: Paretic right vocal cord Supraglottic edema Bowing of vocal cords bilaterally Aspiration of secretions observed with no attempt to clear Recommendation for swallow consult Bedside swallow evaluation Performed post-operative day #5 Weak volitional cough and severely hoarse and hypophonic voice Limited trials at bedside (ice chips and puree), wet vocal quality postswallow and coughing Recommendations to remain NPO and perform instrumental assessment Video Clip #1 17 Videofluoroscopic swallow evaluation Post-operative day #7 Swallow elicited at valleculae Silent aspiration of nectar thickened liquids via teaspoon during the swallow Head turn right/chin tuck Not helpful – persistent silent aspiration Recommendations Mechanical soft dysphagia (no mixed textures) diet with honey thick liquids Liquids via teaspoon only Medications crushed with puree items, per Pharmacist Reconsult ENT for consideration of management; notified of swallow study results ENT management Post-operative day #8 Clinic procedure under local anesthesia; excellent pt tolerance Bilateral cymetra injection, R>L Resume restricted diet with repeat instrumental exam the following day **Immediate improvement in vocal quality and cough noted Cymetra Micronized human dermis (as documented by www.Lifecell.com): o Contains all elements needed to replace tissue: Collagen and elastin – provide means for cell repopulation Proteoglycans and proteins – allow patient’s own cells to revascularize and repopulate Advantages Can be done in clinic or operating room Quick results Good patient tolerance; nice alternative to using patient’s own tissue 18 Disadvantages Variable resorption Variable effectiveness; ranges from 3-12 months Expensive Further research needed Video Clip #2 Videofluoroscopic swallow evaluation Performed post-operative day #9 Pharyngeal delay to valleculae No laryngeal penetration or aspiration No postural changes or compensatory strategies needed Esophageal stasis noted with screening Recommendations General diet with thin liquids Medications whole with water Upright during and after meals Follow-up Patient discharged home the following morning, post-op day #10 Breakfast observed prior to discharge, no dysphagia documented with general diet and thin liquids F/u with ENT on outpatient basis – no further management warranted Take Home Message Certain cases where therapeutic and/or compensatory strategies are not immediately helpful Resort to modified diet as last option; often needed only for a limited time Working and communicating with other teams (ENT, GI, Pulmonary, Respiratory therapy) can improve patient outcomes 19 Referral to Prosthodontist for Palatal Augmentation Prosthesis Rachael E. Kammer, M.S.,CCC-SLP University of Wisconsin Medical School Madison, Wisconsin Patient 53 year old male T4 N2c SCCA right oral tongue, tonsil, base of tongue No previous treatment Treatment Surgery –S/P near total glossectomy –Composite resection of right pharyngeal wall –Partial resection of right mandibular body –Rectus abdominus free tissue transfer –Bilateral neck dissection G-tube Post-Op visit Seen for clinical swallow evaluation during first post-operative visit –Oral motor exam revealed flap in place at floor of mouth – No significant movement of flap when tongue range of motion attempted –Thin liquid trial; obvious s/s aspiration Sent for radiotherapy at outside facility –Rec NPO, pt to attempt tongue ROM ex during RT Post RT Visit Pt able to achieve minimum ROM with flap and residual tongue Reports that he is drinking liquids and eating puree foods (not recommended!) Decided to proceed to VFSS 20 VFSS #1 Results Oral phase –Decreased oral transit, pooling at anterior floor of mouth –Nasal regurgitation Pharyngeal phase –Delay to pyriform sinuses –Fibrotic epiglottis –Penetration to vocal folds, frequent aspiration but able to clear Recommendations Start liquid diet Head tilt back strategy Super supraglottic swallow Referral for palatal augmentation prosthesis (palatal drop) Palatal Drop prosthesis Lowers palatal vault so that tongue with reduced range of motion can make better contact with palate –May improve articulation and oral transit Referral Prosthodontist Sent copies of operative report – Helpful for prosthodontist to know details of resection and reconstruction Sent copy of VFSS (report and video) Called to verbally explain what is needed Asked pt to return after he receives prosthetic 21 Construction Impressions taken First model constructed Placed in pt’s mouth, with paste spread on prosthetic Pt articulates and swallows – prosthodontist can see where tongue makes contact, then modify prosthetic Pt sent back for repeat VFSS VFSS #2 Pt reported he was wearing palatal drop all the time Reported improved speech intelligibility Wanted to eat more consistencies VFSS #2 Results Oral phase –Improved tongue to palate contact –Improved oral transit – can tolerate puree now –Decreased oral cavity pooling Pharyngeal phase –Same characteristics, but more efficient –Premature spillage to pyriform sinuses –Penetration to vocal folds –Occasional trace aspiration, but pt clears with cough –Fibrotic epiglottis Recommendations Advance to puree diet, thin liquids Head tilt back and liquid wash helpful Super supraglottic swallow Wear prosthetic all the time – Often patients will need occasional adjustment from prosthodontist, since tongue can now make contact the resistance will lead to improved tongue range of motion 22 Research Davis (1987) –Palatal prosthetic leads to: o More efficient swallow o Decreased aspiration o More consistencies in diet o Improved articulation of velar and alveolar phonemes Research Logemann (1989) –Palatal drop devices resulted in: o Improved swallow efficiency o Increased duration of tongue contact to pharyngeal wall o Improved transit of bolus from valleculae to pyriform sinuses Conclusions 50% or greater glossectomy – palatal drop prosthesis can improve articulation and oral pharyngeal swallow Good relationship and communication with prosthodontist facilitates creation of appropriate and beneficial prosthetics Bibliography Davis, J., Lazarus, C., Logemann, J., Hurst, P. (1987) Effect of a maxillary glossectomy prosthesis on articulation and swallowing. J of Prosthetic Dentistry; 57(6): 715-719. Logemann, J., Kahrilas, P., Hurst, Pt., Davis, J., Krugler, C. (1989) Effects of intraoral prosthetics on swallowing in patients with oral cancer. Dysphagia; 4(2):118-20. 23 Notes: 24 Dysphagia & H/N Cancer Surgery Michelle Bernstein, MA CCC-SLP University of Miami Miami, Florida History WH is an 82-YOM presenting to our clinic on 3/02/05 s/p 2 month h/o sore throat & odynophagia. Pt. denied physical difficulty swallowing. 8 lb. weight loss over the past 2 months. Pt. s/p radiation 30 yrs ago for non-Hodgkin’s lymphoma with tonsillar involvement; underwent tonsillectomy. Residual xerostomia. History, cont. Biopsy pathology indicates T2 N0 squamous cell carcinoma of the right oropharynx. Co-morbidities: o significant cardiac disease (tachycardia) o internal defibrillator o Pacemaker o h/o TIA x2 (most recent 2 yrs ago) o elevated cholesterol. History, cont. WH underwent transhyoid pharyngectomy with ipsilateral neck dissection & pectoralis flap reconstruction 3/18/06. 3/31/06 - Presented for MBS (~2 wks p surgery). *Coming from a distance to clinic. Tracheostomy tube removed last wk (small residual healing trach site requiring occlusion for improved voice). NG tube currently in place. Modified Barium Swallow Study Video Clip from 3/31/06 25 MBS Results 3/31/05 – Oral prep: increased time to form and propel cohesive bolus. – Oral: significantly delayed swallow initiation. – Pharyngeal: sig. for ↓ TB retraction, ↓ laryngeal motion, no epiglottic inversion, mn. pharyngeal contraction, & resultant incomplete CP relaxation MBS Results, cont. 3/31/05 – Aspiration observed after swallow resulting from pooled barium spilling into unprotected airway. – Pt. sensate, but unsuccessful cough response in clearing aspirated material from airway. – Maneuvers/strategies attempted, but cont. ineffective swallow observed. – Limited study secondary to discomfort . Recommendations 3/31/05 – NPO secondary to significant risk of aspiration. – Consider PEG placement. – Initiated on swallowing therapy exercises with oral facilitative tasks for attempts at improving strength and resistance of OP musculature. Recommendations, cont. 3/31/05 – Practiced strategies incl. Mendelsohn Maneuvers/ SuperSupraglottic Swallow techniques. – *WH will continue with recommendations at his living facility. – Repeat MBS in 1 month. 26 Repeat MBS Video Clips –5/13/05* –6/9/05 –9/9/05 –12/7/05* –3/20/06* Swallowing Therapy Tongue base exercises –Masako –Resistance (tongue press tasks) Laryngeal Elevation –Falsetto tasks –Mendelsohn Maneuvers Airway Protection Exercises Slowly advanced oral diet as WH demonstrated improved airway protection. Final MBS Video Clip from 4/27/06 MBS Results 4/27/06 – Oral prep: unremarkable – Oral stage: mn. inconsistent delay for triggering swallow response – Pharyngeal: residual ↓ TB retraction, ↓ laryngeal motion, sig. improved pharyngeal contraction, & resultant mn. incomplete CP relaxation 27 MBS Results, cont. 4/27/06 – Pt. spontaneously utilizes Mendelsohn maneuver/SSS while demonstrating good airway protection. – No aspiration observed. – PEG tube subsequently removed. – Pt. returns for f/u with H/N surgeon on a frequent basis with continued reports of doing well with no respiratory distress, complete oral nutrition, & excellent quality of life. 28 Communicating to Referral Source Extended Care and Hospital Therapists Make A Way for Optimal Patient Care Angela Campanelli, MS, CCC-SLP, BRS-S Kettering Medical Center Kettering, Ohio Therapist Reports to Therapist ECF therapist calls to schedule an emergent video-fluoroscopic swallow study She describes the problem and patient as follows: Problems spaghetti, and chocolate exuded from unhealed trach site the night before Rice Krispies exited the unhealed trach site during breakfast that morning The Patient 58 year old female Impaired cognition/insight, not following through on precautions (though she had been a teacher) Onset 11 months prior Respiratory failure (CHF, pneumonia), tracheostomy, mechanical ventilation Therapist to Therapist ECF therapist accompanies patient to exam Explains that the patient has exercised her right to not have a modified diet Gives detailed history of events 29 Pre-Morbid Medical History Morbid obesity Gastric by-pass 10 yrs ago Osteo-arthritis/TKR GERD Psychiatric history of bipolar and panic disorder (adult child of violent alcoholic) Sequence of Acute Events Jan 1: bronchoscopy Jan 4: tracheostomy Jan 6: colonoscopy (diverticular disease) Jan 7: upper endoscopy Jan 18: transferred to sub-acute Feb 8: transfer to ECF Current Status Lost 100 pounds (morbid obesity) Weaned from ventilator/ Passy Muir Decannulated 8 months after arriving at ECF (10/05) Patient Rights: regular diet with thin Transfers min-mod assist W/C for distance mobility Medication Lists Sub-Acute 1/05 Resperidol/Xanax ASA Guaifenesin/Theophylline Zelnorm Prevacid K-Dur Coreg/Lasix ECF 11/05 Zoloft/Xanax/Aricept ASA Mucinex/Claritan Zelnorm Prevacid (9:00 AM) Lasix 30 Therapists and Radiologist Discuss Reason for the Study Need to find out how the food finds its way out the stoma ECF therapist brought patient’s favorite candy and some pie to mimic “real life” Video-Fluoroscopy Findings Early entry/poor bolus containment Swallow reflex triggers 1-2 seconds after contrast in pharynx Minimal vallecular and pyriform sinus stasis of thin after the swallow Critical VFSS Observation She had no dramatic findings until 13 minutes into the study. Self feeding a favorite candy bar, she took a large bite, lost it over the base of the tongue, and most of the solid bolus penetrated the airway. This was the critical moment, illustrating the end result of multiple disorders. What is the disorder? Poor sensory awareness, mild delay of the swallow reflex, back of tongue and BOT weakness, mildly diminished laryngeal elevation and behavioral impulsivity contribute to the ultimately severe oral pharyngeal dysphagia. Patient and Therapists Convene The findings were reviewed with the patient Therapists stressed that the patient had a right to choose when well informed of risks and benefits We first identified the patient goals of getting well, eating normally, and leaving the nursing home 31 ECF Therapist Shares MD Concerns ECF physician suggests to re-cannulate with trach tube to “prevent aspiration”a common misperception Plastic Surgery does not want to assist in wound closure due to risk of infection This would allow her to build up sub-glottic air-pressure for safer swallowing Therapists Propose Plan to Patient Wound healing can only be achieved with an NPO status as constant food presence is risk for infection PEG is suggested as temporary The patient agrees Plan includes intensive therapy to improve sensory/motor and strengthening ECF Therapist Presents Proposal to ECF Physician GI consult: o PEG placed ASAP/ NPO status o May have water after oral hygiene Plastic Surgeon Consult: o closes neck wound 4 months after VFSS Repeat VFSS Ordered: o conducted one week after plastic closure. Brief Synopsis: Second VFSS Findings Same disorders but less dysfunction. Penetration-Aspiration Scale: 5/8 as thin liquid penetrated to vocal cords (anterior commissure), residual remained. Only on one of eight drinks! Reflex in one second. Audible upper airway rhonchi and poor distal esophageal clearing raised the question of GERD as the source of aspiration. 32 Therapists’ Convened Brainstormed on how to increase sensory awareness and response. Hospital therapist suggested body scanning and attention to breath. The therapist would guide her to notice her breath, notice it filling her lungs, exiting, then notice throat, vocalize and notice wet quality, and wet quality of airway, and so on… The Rest of The Story Increased body awareness allowed for greater self monitoring. Advanced to all oral diet on regular textures in seven months after first VFSS. Discharged to assisted living 10 months after first VFSS and 21 months after entering Acute Rehab. The End The therapists and engaging physicians continue to discuss challenging patients and push the envelope with sound theory. These novel treatment plans enhance care and expand possibilities. Acknowledgements To all patients who entrust their care to us Jeri Logemann, PhD/CCC-SLP, BRS-S Sharon Rains, MS/CCC-SLP Bernice Klaben, PhD/CCC-SLP, BRS-S Lisa Kelchner, PhD/CCC-SLP, BRS-S Kettering Radiology Department Kettering BMET Department 33 Integrating Clinical and Videofluorographic Data to Direct Patient Care: A Case Study Barbara Grande MS, CCC-SLP, BRS-S Covenant Rehabilitation Services Milwaukee, WI The pt is a 73 y.o. female with recent cardiac artery bypass surgery (CABG) and difficult postoperative course which resulted in prolonged endotracheal intubation and eventual tracheostomy. Pt was recovering well and was transferred to in-pt rehabilitation unit. Pt coded while on rehab unit due to mucous plug and transferred to ICU. Pt improved in ICU and was decannulated, returning to rehabilitation unit. However, she developed increasing shortness of breath accompanied by some inspiratory stridor. Her past history includes (R) thyroid lobectomy 20 years ago which resulted in (R) vocal fold palsy. ENT consult showed new (L) vocal fold palsy possibly due to a recent thyroid enlargement on the (L) or perhaps her recent heart surgery. There was no abduction of either cord on inspiration, and both vocal cords remained in the paramedian position. There was inspiratory stridor and raspy voice. Bilateral vocal fold palsy was causing narrowed glottic airway. While pt was oxygenating satisfactorily, there was concern for fatigue requiring reintubation. Pt was transferred back to ICU should reintubation be required. Per ENT, (L) vocal cord could recover eventually, but it could take 6-12 months. Pt also experienced generalized deconditioning with dysphagia following her heart surgery. A naso-gastric feeding tube was placed which pt tolerated well. The pt continued to improve and was transferred to a medical floor. A video-fluoroscopic swallow study was scheduled. 34 First Video-Fluoroscopic Swallow Study Initial portion of evaluation completed with trach cuff inflated for thin, nectar, honey, pureed. Pt was then suctioned, cuff deflated, and the evaluation continued with thin, nectar and honey only. Compensations attempted: chin tuck, head turn, multiple swallows, restricted bolus size A-P view was deferred due to extensive time in lateral view. Findings From First VFSS Moderate oral dysphagia characterized by decreased bolus control and passive spillage of bolus due to impaired lingual mobility. Severe pharyngeal dysphagia characterized by moderately reduced hyo-laryngeal elevation and absent epiglottic inversion. This resulted in deep laryngeal penetration, aspiration during and after the swallow, and moderate to severe pharyngeal residue. Reduced hyo-laryngeal elevation Absent epiglottic inversion Recommendations NPO and alternative nutrition/hydration Swallow therapy to include: lingual resistance bolus manipulation exercises Mendelsohn Maneuver supraglottic swallow glottal closure exercises thermal stimulation with effortful swallow Pt was transferred back to in-pt rehab unit 2 days later, and swallow therapy was resumed. A follow-up video-fluoroscopic swallow study was completed one month later. 35 Findings from 2nd Videofluoroscopic Swallow Study Most salient features of this study: Persistent limitation in hyo-laryngeal elevation Continued absence of epiglottic inversion These deficits resulted in aspiration, penetration and entrapment of material in valleculae The pt was discharged home after having received swallow therapy in acute care and on in-pt rehab unit. Swallow therapy was continued with Home Health Services. A follow-up swallow study to assess response to therapy and readiness for diet advancement was completed. Findings from 3rd Videofluoroscopic Swallow Study Persistent severe pharyngeal dysphagia with deep penetration and aspiration after the swallow, usually from pyriform sinus residue spilling over into the airway. Risk of aspiration remains high due to absent epiglottic inversion to protect airway as well as from pharyngeal residue. This study does not support improved performance or readiness for diet upgrade. Out-Patient Therapy Initiated and Treatment Provided Lingual resistance Effortful swallow with thermal stimulation to facilitate Masako maneuver Mendelsohn maneuver Trials of Honey consistency liquids; pt trained to evaluate voice quality and to clear and re-swallow if “wet.” Out-Patient Progress Pt progressed in all treatment modalities, increasing Duration of lingual resistance (from 3s to 15s) Frequency of effortful swallow response to thermal stimulation (100% with visible increase in contraction of strap muscles) 36 Number of Masako swallows per session (from 5-10) Duration of Mendelsohn posture (from 5s to 23s) Upgrading of liquid consistency from Honey to Nectar in therapy sessions These clinical markers are often indicative of improved pharyngeal function especially if large gains are achieved. For this reason, a follow-up Video-Fluoroscopic Swallow Study was scheduled. Findings From 4th Video-Fluoroscopic Swallow Study Swallow response is now timely Hyo-laryngeal elevation has increased Epiglottic inversion now occurs occasionally Vallecular and pyriform sinus residue is greatly reduced Penetration/aspiration is infrequent, occurs only with thin liquid and is removed with effective throat clearing when pt is wearing speaking valve Hyo-Laryngeal elevation has increased Epiglottic inversion now occurs occasionally D/C recommendations Upgrade diet to include high mechanical-general diet consistencies. Thin liquid with precautions (use speaking valve for throat clear). Continue home exercise program as instructed. 37 Communication with the Multidisciplinary Team Bernice K. Klaben, Ph.D. CCC-SLP BRS-S The Blaine Block Institute for Voice Analysis and Rehabilitation Dayton, Ohio The University of Cincinnati ENT Voice Center West Chester, Ohio 54 yr old male Shipping and Receiving/Parts Cleaner c/o progressive hoarseness, dysphagia (20 lb wt. loss), ear pain & sore throat for over 4 mos before seeing his physician Smoked 2-3/ppd x 30 yrs. No alcohol use HTN Unremarkable medical hx – umbilical hernia repair Dx epiglottic carcinoma T2 N2c M0 Stage IV Supraglottic resection and bilateral modified neck dissections w/tracheostomy 3/05 Invasive disease – SCC of epiglottis – 3.8cm with metastases in two lymph nodes on the R and 3 on the left with extra capsular extension (5 positive nodes out of 53). Spinal accessory nerve and internal jugular veins were preserved Nutritional intake – PEG placement prior to surgery Meds – Diovan, Zantac, Zetia, Albuterol prn Lower teeth extraction – upper dentures Wound infection in lower neck – drained, packed, prescribed antibiotics 8 wks after surgery pt started combined modality of chemotherapy & radiation Received IMRT of 5800 cGy to pharynx and neck areas (29 fractions over 39 days) from 5-7/05 plus Taxol & Carboplatin ENT referred for a VLS 5/05 to examine the larynx prior to chemo and radiation tx Occluded trach for speaking Started dysphagia therapy – supraglottic swallow and lingual ROM + strengthening + oral care 38 VLS After Surgery – Before Chemo/Radiation Pt was using supraglottic swallow and eating soft mechanical along with tube feeds until 1mo after treatments started (23 rad tx & 6 chemo tx) Increased soreness in oropharyngeal area secondary to mucositis, xerostomia, edema Thick secretions but continued drinking room temp water with supraglottic swallow Voice 7 (1-7 scale, 7= worse) Pain 5/10 1 mo after txs was NPO – choked Restricted head turn to L Initiated supraglottic swallow with 2 ml of water ENT recommended VFSS ENT recommended PT for neck and shoulders VFSS 1mo After Chemo/Radiation Continued dysphagia therapy with pt doing exercises daily at home Slow healing, neck edmatous, thick secretions Pt filed for disability Lost his job Obtained dentures Trach removed 4mos following completion of chemo/radiation Follow-up VLS VLS 4mos After VFSS Overall improvement Pt unable to advance beyond thin and thick liquids using supraglottic swallow VFSS recommended Results of VFSS 39 Questioned the etiology of the upper esophageal stasis (stricture or tightness in the distal pharynx around C4-6) Reviewed with the ENT Pt referred to Gastroenterologist – esophageal dilation was performed Pt experienced immediate improvement in swallowing and was eating a regular diet using supraglottic swallow Summary Important for the treating dysphagia therapist to maintain dialogue with the pt, surgeon and SLP performing the VFSS Pt was treated at 6 different facilities Pt followed for 1yr before he became completely oral following dysphagia therapy and eventually esophageal dilation Peg tube removed Continues to be cancer free Released to work but not able to find a job Went back to smoking 40 Zenker’s Diverticulum in a Patient with Cerebellar Hemorrhage Amy B. Kelly, M.A., CCC-SLP Evanston Northwestern Healthcare Evanston, Illinois Case Presentation 86 y.o female who presented to the ER with headache and vertigo. CT scan revealed 3.6 x 3.7 cm left cerebellar hemorrhage with mass effect into 4th ventricle. Taken to the OR for left occipital craniectomy for evacuation of hematoma. Post-operative course complicated by decreased mental status, accelerated hypertension and congestive heart failure, UTI and aspiration pneumonia. Initial Management of Dysphagia SLP received order for clinical swallow evaluation (BSSE) post – op day 2. BSSE revealed mild oral/moderate pharyngeal dysphagia clinically, characterized by decreased bolus control, persistent throat clear and hoarse, wet vocal quality all consistencies. Recommendation - continued NPO with daily reassessment by SLP. Results communicated to ICU service, Neurosurgery PA, patient and family. Dobhoff tube placed by ICU service given above results. Ongoing Reassessment SLP reassessed clinically x 2 (over 2 day period): Recommendations NPO with meds crushed in puree by post-op day 4. 41 Recommendation for VFS made at that time via discussion with ICU service. Vocal quality continued to be assessed as breathy, hoarse and diplophonic. Objective Assessment VFS performed post-op day 5 Results: o Decreased oral control o Decreased BOT retraction o Decreased laryngeal elevation o Decreased A-P vestibule closure o Decreased vocal fold closure o Incidental finding of large Zenker’s diverticulum Aspiration occurred before, during and after the swallow. Recommendation was for NPO. Results discussed with ICU service, Neurosurgery, patient and family. Request for ENT and GI consult given evidence of TVC disorder and very large Zenker’s diverticulum. Specialist Consults ENT and GI consulted. Fiberoptic laryngoscopy at bedside revealed L TVC paralysis, with cord in the paramedian position. GI and SLP discussed results of VFS; GI proceeded with PEG. ENT planned for repair of Zenker’s diverticulum when medically stable, although concerned re: TVC paralysis. 42 Ongoing Speech Treatment Speech Pathology proceeded with swallow and voice therapy. Bolus control exercises. BOT retraction exercises. Laryngeal elevation exercises, especially pitch glides which benefit both voice/ swallow function. Pt unable to perform Shaker exercise or effortful breath hold exercise. Surgical Intervention S/P open repair of Zenker’s diverticulum with cricopharyngeal myotomy; endoscopic repair not possible secondary to chronic DJD of cervical spine. ENT contacted SLP, requesting repeat VFS 2 days post-repair of diverticulum. Indicated he was not concerned re: esophageal leak given results of procedure, and advised SLP to proceed with regular VFS protocol. Objective Reassessment Repeat VFS revealed significantly improved swallow function & good repair of Zenker’s diverticulum. Pt continued to aspirate thin liquids secondary to L TVC paralysis. Head turn to L helped eliminate aspiration, however, pt c/o neck pain and was judged cognitively to be unreliable for postural maneuver at that time. Recommendation was for mechanical soft diet with nectar thick liquids. Recommendations shared with hospitalist, RN, dietician and pt/family. 43 Discharge Status Patient d/c’d from hospital after short stay on both subacute and acute rehabilitation units. PEG tube removed 10 days after 2nd VFS per discussion with SLP, dietician and hospitalist, after patient’s oral intake proved to be safe/adequate. Patient was d/c’d home on modified diet (nectar thick liquids only). SLP contacted discharge planner to ensure order and scheduling information was provided for follow up VFS 4 weeks post d/c ( or sooner IF vocal quality improved significantly). SLP contacted home health therapist to review VFS results and therapeutic recommendations (continuing voice tx). Per discussion with ENT, plan to proceed with thyroplasty if no improvement on f/u VFS. Outpatient Follow-up Patient returned for a follow-up VFS 1 month after the previous study. Patient had been receiving continued swallow and voice therapy via home health. Continued on general diet with nectar thick liquids at home. Repeat VFS revealed trace superficial penetration with thin liquids. No aspiration. Recommendation was for general diet, all liquids; continue voice therapy as dysphonia improved but not resolved. Discussed results with home health SLP and ENT, who decided to wait on thyroplasty, as not needed for swallow function/airway protection. 44 Note: 45 Speaker biographies Mary J. Bacon, MA, CCC-SLP, received her undergraduate degree from Miami University, Oxford, Ohio and her graduate degree from Northern Illinois University. She is a clinical educator at Rush University Medical Center, Chicago Illinois and teaches dysphagia as well as coursework pertaining to head and neck cancer to graduate students at Rush University. She has evaluated and treated patients with dysphagia for more than 25 years. Amy Baillies MS, CCC-SLP, received her bachelor's and master's degrees from the University of Wisconsin-Madison. She currently works at the University of Wisconsin Hospital and Clinics, where she specializes in adult dysphagia evaluation and treatment. Michelle Bernstein, MA, CCC-SLP, is a speech-language pathologist in the Department of Otolaryngology at the University of Miami, Miller School of Medicine. Her clinical practice is limited to the management of voice and swallowing disorders and head and neck cancer rehabilitation. She is involved in a number of multi-institutional research grants and contributes to publications in the areas of voice and swallowing assessment and treatments. Angela Campanelli MS, CCC-SLP, BRS-S, is a Senior Therapist at Kettering Medical Center in Ohio with a Master’s degree from West Virginia University. A dysphagia specialist for 20 years, she is a Charter Member of Board Recognized Specialist in Swallowing. Her practice includes providing VFSS and therapy to patients from ENT including head and neck cancer, pulmonary, critical care and neurology. Joy Gaziano, MS, CCC-SLP, is Coordinator of Speech Pathology at H Lee Moffitt Cancer Center, Tampa, FL. Joy authored a chapter in the text "Swallowing Interventions in Oncology". Her clinical and research interests are in the areas of dysphagia, voice and head and neck cancer rehabilitation. Dysphagia Specialist for Covenant Rehabilitation Services, Barbara Grande MS, CCC-SLP, BRS-S, has lectured on dysphagia and mentored colleagues in performing videofluoroscopy. She participates in two national clinical trials studying efficacy of swallowing therapy, and was an initial contributor of data to the Shaker Exercise Protocol. Barbara also served on ASHA's SubCommittee for Specialty Recognition in Dysphagia. Rachael Kammer MS, CCC-SLP, received her bachelor’s degree from the University of Michigan, and master’s degree from Arizona State University. 46 She started her career in Chicago at Loyola University, and is now at the University of Wisconsin, where she specializes in swallowing disorders, head/neck cancer swallowing rehabilitation, and alaryngeal voice restoration. Amy Kelly, MA, CCC-SLP, is a senior staff member and manager of the speech pathology department at Evanston Northwestern Healthcare, Illinois. Her clinical practice has focused on the areas of adult neurogenics, head and neck cancer, and dysphagia in infant through adult populations. Bernice Klaben, PhD, CCC-SLP, Director of Clinical Practice at the Blaine Block Institute for Voice Analysis and Rehabilitation, Ohio, co-authored Clinical Voice Pathology: Theory and Management. Serves on DIV 3 Steering Committee. Specializes in voice disorders, laryngectomy voice restoration, paradoxical vocal cord dysfunction, swallowing problems in head and neck patients. Kristin Larsen, MA, CCC-SLP, received her MA in speech-language pathology from Northwestern University. She is currently a staff speech pathologist at the Northwestern University Voice, Speech, Language Service and Swallowing Center and is a lecturer in the Department of Communication Sciences and Disorders of Northwestern University. Jeri Logemann, Ph.D., CCC-SLP, BRS-S is Ralph and Jean Sundin Professor of Communication Sciences and Disorders at Northwestern University, and Professor of Otolaryngology and Maxillofacial Surgery and Neurology at Northwestern University Medical School. She has published and lectured widely both nationally and internationally on evaluation and treatment of swallowing disorders. 47
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