Speech Language Pathology Swallow Evaluation Sample Report


HISTORY OF PRESENT ILLNESS:
The patient was seen in joint consultation with the departments of speech pathology and radiology for a modified barium swallow.  The patient is a (XX)-year-old male with a history of stage IV left base of the tongue squamous cell carcinoma. He underwent chemoradiation treatment in the past and had PEG tube placed during his treatment for primary nutritional support. The patient has been followed by this department for dysphagia therapy and objective swallowing examinations. The patient has been seen through the department of gastroenterology for serial dilations due to upper esophageal narrowing secondary to prior radiation therapy. His PEG tube was subsequently pulled and most recent modified barium swallow performed revealed mild oropharyngeal dysphagia characterized by reduced pharyngeal bolus propulsion, moderately decreased hyolaryngeal elevation and good airway protection, without laryngeal penetration or aspiration. There was pooling in the vallecula after more dense consistencies. This cleared successfully with use of left head turn, chin tuck and a subsequent liquid wash. The patient had excellent passage through the cricopharyngeus at that time.

Today's evaluation was scheduled 6 months after the last MBS to monitor the patient's progress over time. He reports that his last dilation was approximately 3 months ago. Since that time, he has not noted major changes in his swallow. He still has difficulty with solids. He is unsure if the left head turn makes any significant difference at this time. He is crushing most of his medications and taking them with food. He is otherwise unable to swallow them successfully with a sip of a drink. He is maintaining his weight and has been doing so for the past 6 months. He has no recent history of pneumonia. He is managing on a soft solid diet with thin liquids at this time.

SWALLOWING EVALUATION:
The patient was imaged standing in the lateral and anterior to posterior projection. The patient was administered graduated size boluses of thin liquid barium, nectar thick barium and semisolid. Particulate solid was deferred as well as a 13 mm barium tablet secondary to visualized deficits. Oral phase revealed good bolus acceptance and containment with timely trigger for all liquids. There is labored anterior to posterior transit with delayed trigger of pharyngeal swallow and tongue pumping prior to trigger of pharyngeal swallow with semisolids. This appears secondary to the patient's xerostomia, making it difficult for him to form a soft and moist bolus prior to trigger of pharyngeal swallow. The patient was noted to have weak pharyngeal bolus propulsion and moderately reduced hyolaryngeal elevation. The patient does not get full epiglottic deflection during the swallow, thus allowing for deep laryngeal penetration with thin and nectar thick barium into the endolarynx, to which he does not throat clear in response. Cued throat clear successfully clears the airway. There is constriction through the upper esophagus with weak pharyngeal contractility. Subsequently, there is retention in the vallecula and piriform sinuses with all consistencies. The patient is able to swallow 2 to 3 times to achieve clearance for liquids. More dense consistencies such as particulate solids pool heavily in the vallecula. Multiple left head turn, chin tuck swallows and a sip of thin liquid subsequently helps to clear the vallecula. In the anterior to posterior projection, the barium was symmetric. On the Rosenbek Penetration/Aspiration Scale, severity level rating of 3 with liquids indicating that contrast remained above the vocal folds with visible residue remaining, and fair level rating of 1 for semisolids indicating that contrast did not enter the airway. Images were obtained in synapse for review of proximal esophageal narrowing.

SUMMARY AND IMPRESSION:
Moderate oropharyngeal dysphagia characterized by reduced pharyngeal bolus propulsion, moderately decreased hyolaryngeal elevation and narrowing through the pharynx and upper esophagus. Weak pharyngeal bolus propulsion and incomplete epiglottic deflection results in pooling in the vallecula with all consistencies. This is more evident with semisolid consistencies and liquids. Subsequent weak pharyngeal contractility and narrowing through the upper esophagus makes it difficult for the patient to achieve clearance of residue in the vallecula. Use of left head turn, chin tuck and subsequent liquid wash appears to be the best strategy at this time for clearing residue. The patient has laryngeal penetration with all liquids, subsequent from spillover from the vallecula into the endolarynx. He does not consistently throat clear in response, although cued throat clear helps to clear any penetrated materials.

At this time, the patient was counseled to use intermittent throat clear and re-swallow during meals and after liquids and to utilize left head turn, chin tuck with subsequent liquid wash with soft solids. Food should be very soft and moist and near ground/chopped consistencies. This is similar to what the patient is currently eating. Medications should continue to be crushed. Given that he has not had a dilation in approximately 3 months, we will refer back to Gastroenterology for question of further dilation to assist with achievement of pharyngeal clearance. The patient can be seen back for repeat testing as indicated after repeat dilation and should ultimately continue to be monitored via periodic objective swallowing study. The patient is continuing with his dysphagia therapy exercises as is recommended and this will help to maintain swallowing function and hopefully continue to strengthen it as well. The patient can follow up with speech pathology after any further dilation.


RECOMMENDATIONS:
Soft moist consistencies, near ground/chopped consistencies with thin liquids; medications crushed in puree; intermittent throat clear re-swallow after liquids; use of left head turn, chin tuck followed by liquid wash for solid foods; upright 90 degrees with all p.o.; decrease bolus size and rate of presentation; alternate bites and sips; follow up with Gastroenterology for question of repeat dilation; further objective testing and support from speech pathology after followup with Gastroenterology; to contact with any further questions.











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