1

Joy Gaziano MA, CCC-SLP, BRSS

Mary J. Bacon, M.A. CCC-SLP, BRS-S

Mario A. Landera, M.A., CCC-SLP

Vicki Lewis, M.A., CCC-SLP

Bernice K. Klaben, Ph.D. CCC/SLP BRS-S

Linda Stachowiak, MS CCC-SLP, BRS-S

Jerilyn A. Logemann, Ph.D., CCC-SLP, BRS-S

2
 We are seeing dysphagic patients of various
ages including 90 + years old with multiple
medical problems (often 5 to 6 medical
diagnosis)

 No studies of patients of every type are

available

 This presentation focuses on methods to

collect individualized EPB data on unique
dysphagic patients
3
 Joy Gaziano MA, CCC-SLP, BRSS
USF Center For Swallowing Disorders
Tampa, Florida
ASHA 2012

4
 26 yo female with sudden onset dysphagia 3
months ago while swallowing scrambled eggs.
Sensation of “wall in the throat” that would not
allow her to swallow.

 Progression of symptoms to include

downgrade to liquid diet, 10 lb. weight loss,
anxiety with swallowing.

 Pills lodge in back of throat. Heartburn with all

meals.
5
 Similar episode 3 years ago with meat
sandwich.

 EGD (18 and 8 months ago) showed hiatal

hernia, esophageal ulcerations. On Prevacid
solutabs and Asthmanex

 MBS (2 months ago) stopped when she spit

out applesauce.

 Psychology grad student. Planning wedding.

6
 How can history guide decision making?

 How can you maximize MBS efficacy?

 How can literature guide assessment?

 How can literature guide tx plan?

7
 Psychosomatic disorder -change in function
suggesting a physical disorder, but is an expression
of psychological conflict. Panic, anxiety, conversion.

 Anatomic disorder- Zenker diverticulum, upper

esophageal web, tongue base tumor, TMJ
dysfunction, hyperplastic tonsils, cervical
osteophytes, cyst, thyroid disorder, esophageal
stricture.

 Physiologic disorder –increased pharyngeal muscle

tension, reflux, esophageal motor disorders,
inflammation, infection. 8
9
 View oral phase
 (AP and lateral)

 Compensatory strategies under fluoroscopy

 Liquid push, chin tuck,

 Reduce X-ray exposure

 Fewer swallow trials

 Esophageal sweep (Allen, et.al, 2012)

 Esophageal component/etiology

10
 Characterized by oral apraxia with intact speech, pharyngo-
esophageal and neurologic functions (ASHA website).
 Cases reported internationally (deLucas-Taracena, 2006;
Ciyiltepe, 2006; Okada, 2007).
 Accounted for very few cases at a major US swallowing
center (Ravich,1983 ).
 May have associated psychiatric conditions
(panic/anxiety/conversion) (Deary, 1994).
 No more likely to have major psychopathology.

11
 Dysphagia and eating disorders
 No reports in lit. of swallowing problems for patients with eating
disorders until 2012 (Holmes, et al., 2012).
 PDPs score lower on eating disorder inventory, but higher on
general measures of distress (Barofsky et al., 1988).
 Dysphagia and “globus hystericus”
 Can occur with dysphagia in absence of radiographic findings
on MBS.
 Referred sensation from esophagus
 Frequently seen in posterior laryngeal swelling due to acid
reflux injury (Kaufman et. al, 1996)
 High incidence of esophageal motor disorders in patients with
globus sensation (Moser et. al, 1998)

12
 Oropharyngeal manifestations of esophageal
dysphagia

 Pediatric swallowing treatment

 Anxiety management

 SEMG assisted swallowing treatment

 Interdisciplinary team management

 Personal experience
13
 Barium Swallow

 Esophageal manometry

 EGD

 pH study-Bravo or 24 hour dual channel

study
14
 Education and participation in tx goals.

 Relaxation exercises to identify areas of increased

tension and manage them before/during practice
and meals.

 Contain food/liquid in oral cavity and place in

central groove of tongue prior to initiation of
swallow.

 Maintain oropharyngeal relaxation just prior to

swallow (+/-EMG).

15
 Form into cohesive
bolus

 Maintain bolus in central

groove

 Maintain oropharyngeal
muscle relaxation prior
to swallow

 Decrease delay in
initiation

16
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 Systematically advance to target
textures/volumes/environments.

 Use compensatory strategies as

indicated (chin tuck, liquid push, dry
swallow).

 Maintain diet log for accountability,

motivation and reinforcement.
18
19
Mary J Bacon, MA, CCC-SLP, BRS-S
Rush University Medical Center
Chicago, Illinois

20
 How does the speech pathologist plan
treatment?

 How does the speech pathologist track

progress?

21
 Evidence-based practice is the integration of
(1) clinical expertise/expert opinion (2) external
scientific evidence (3) client/patient/caregiver
values to provide high-quality services
reflecting the needs and choices of individuals
served

(Sackett et al., 1996) 22

 The pt was treated with radiation therapy and
chemotherapy – concurrent

 Due to bilateral neck nodes, left and right

modified radical neck dissections were
performed following the combined modality
treatment

23
 Few articles found

 Base of tongue and tonsil pts together in

groups

 Too few when separate out the tonsil patients

 Little or no information provided about the

speech pathology treatment regimen used

24
 Clinical swallowing evaluation revealed
moderate dysphagia with signs of pharyngeal
residue and possible aspiration

 Fluoroscopic swallow study scheduled

25
 Adequate sample with challenges and trials

 Thin, nectar, pudding, cracker, pt-controlled

drinks as well as calibrated boluses, lateral and
P-A views

 A variety of compensations and maneuvers

were tried during the swallow study

26
 Observe for

base of tongue to pharyngeal wall approximation

hyolaryngeal elevation/pharyngeal shortening

penetration (vestibule closure) with aspiration

after swallows

vallecular residue/not much pyriform residue

27
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 Analysis must tease out the physiologic
impairments that are in fact causing swallowing
dysfunction for the patient
 Then swallow exercises for which there is
evidence may be applied
 Similarly, compensations may be identified as
beneficial for the individual pt in question
 If beneficial on fluoro for pt – instant
evidence!
 We have literature support for
compensations also 34
 To maximize BOT to pharyngeal wall
approximation
 Tongue anchor (Masako) Exercises
 To maximize hyolaryngeal elevation
 Head lift (Shaker) exercises
 To maximize full closure of the laryngeal
vestibule
 Breath hold exercises
 In addition, IOPI measures revealed tongue
strength half of that expected for an adult male
 Tongue press exercises
35
 Masako (Fujiu & Logemann, 1996)

 Shaker (Shaker, et al., 2002)

 Breath hold (Ohmae, et al., 1996)

 Tongue press (Robbins, et al., 2007)

36
 For head lift (Shaker) follow protocol studied,
Gastroenterology, 2002

 For tongue press follow protocol studied, Clin.

Interventions in aging, 2008

 For Masako and for laryngeal closure minimum

25X per day (e.g.10 reps., 3x per day) 6 days
per week for 6 weeks (customary)

37
 One month later clinical evaluation revealed
 3 swallows per tsp liquid, vs. 5-6 at previous
clinical evaluation
 Review of exercise regimen
 Masako – pt ready for additional tongue protrusion
 Shaker – non-adherence; reduction of number
instituted to promote compliance
 Breath hold – increase duration to 5 seconds and
incorporate into supraglottic swallow sequence
 Tongue presses – IOPI revealed improvements of ~
10 K Pa for both anterior and posterior tongue to
palate pressures. Pt to continue
38
 Clinical evaluation revealed 1 tsp water
required only a single swallow

 No throat clear after tsp, though throat clear

noted after pt-controlled drinking

 IOPI measure showed additional slight

improvement of ~ 3 K Pa

 Feeding tube removed

39
 Observe for
 No penetration and no aspiration
 Vallecular residue cleared with single liquid wash
 Pharyngeal residue cleared with one additional “dry
swallow”

 Compare
 Hyolaryngeal elevation
 BOT to pharyngeal wall approximation
 Vestibule closure

40
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 Habituate use of a second swallow (double
swallow)
 Effortful swallow exercise to be done daily
 A single exercise, easily incorporated into daily routine,
with components of most other exercises prescribed
(Hind, et al., 2001)
 Tongue press
 Activation of hyolaryngeal musculature
 Longer vestibule closure
 Longer pharyngeal contraction
 A series of exercises routinely used with RT pts
was taught and provided also (after Kulbersh, et al., 2006
and van der Molen, et al., 2010)

47
 ECOG Performance Status: (foot note -
ECOG PS provided by Eastern Cooperative
Oncology Group)

 Grade 0 - Fully active, able to carry on all pre-

disease performance without restriction.

48
 Even with a patient who does not fall into a well-
studied diagnostic group,

 with proper analysis

 of an adequate sample of behavior

 and good clinical data at follow up visits

 The speech-language pathologist can develop an

evidence based, comprehensive dysphagia
management plan

49
Mario A. Landera, M.A., CCC-SLP
Clinical Instructor
Dept. of Otolaryngology
University of Miami
Miller School of Medicine

50
 72 y.o. Hispanic male presents to ENT clinic on
June of 2012 with deteriorating voice over the
past 1-2 months

 Previously underwent partial laryngectomy

involving the left thyroid cartilage 16 years prior
due to chondrosarcoma

 History of smoking 1ppd x30 years; quit 30

years ago; no ETOH

 Reports no problem swallowing

51
 Fiberoptic exam performed
 Reddish mass along false vocal fold
prolapsing into the larynx

 CT scan
 Evidence of recurrent carcinoma

 Biopsy
 Recurrent chondrosarcoma of the right
thyroid cartilage
52
 July of 2012

 Underwent supracricoid laryngectomy

• Tracheostomy tube

• PEG tube

53
54
 Structures removed
 True vocal folds
 False vocal folds
 Paraglottic spaces
 Entire thyroid cartilage

 At least one functional arytenoid is preserved

 Extended resections, may also remove

 Preepiglottic space
 Epiglottis

55
 Swallowing?

 Voicing?

56
What do you see?

57
58
 Breath-hold (Junko et
al., 2006; Donzelli &
Brady, 2004; Ohmae et
al., 1996; Martin et al.,
1993)

 Improves glottal
closure

 Patient instructed to
hold breath before
and during swallow

59
 Effortful swallow (Huckabee et al., 2005;
Lazarus et al., 2002; Bulow et al., 2001; Hind et
al., 2001)

 Increases oral and base of tongue motion;

reduces residue post-swallow

 Patient instructed to deliberately increase

effort when swallowing by squeezing mouth
and throat
60
 Masako maneuver
(Lazarus et al., 2002;
Fujiu & Logemann,
1996)

 Increases base of
tongue retraction and
posterior pharyngeal
wall contraction:

61
 Mendelsohn maneuver (Boden et al., 2006;
Ding et al., 2002; Lazarus et al., 2002; Dodds
et al., 1988)

 Improves laryngeal motion to separate from

bolus passage

 Increases and widens opening of

cricopharyngeus/upper esophageal sphincter
to prevent residue post-swallow
62
 Super-supraglottic swallow (Boden et al., 2006;
Van Daele et al., 2005; Chaudhuri et al., 2002;
Lazarus et al., 2002; Logemann et al., 1997)

 Closes airway at level of true and false vocal

folds by bringing arytenoids more anterior
narrowing the supraglottic airway

63
What do you see?

64
65
What do you see?

66
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 Boden, K., Hallgren, A., & Witt Hedstrom, H. (2006). Effects of three different swallow maneuvers
analyzed by videomanometry. Acta Radiology, 47, 628-633
 Bülow, M., Olsson, R., & Ekberg, O. (2001). Videomanometric analysis of supraglottic swallow,
effortful swallow, and chin tuck in patients with pharyngeal dysfunction. Dysphagia, 16, 190-195
 Chaudhuri, G., Hildner, C.D., Brady, S., Hutchins, B., Aliga, N., & Abadilla, E. (2002).
Cardiovascular effects of the supraglottic and super-supraglottic swallowing maneuvers in stroke
patients with dysphagia. Dysphagia, 17, 19-23
 Ding, R., Larson, C.R., Logemann, J.A., & Rademaker, A.W. (2002). Surface electromyographic
and electroglottographic studies in normal subjects under two swallow conditions: normal and
during the Mendelsohn maneuver. Dysphagia, 17, 1-12
 Dodds, W.J., Man, K.M., Cook, I.H|., Kahrilas, P.J., Stewart, E.T., & Kern, M.K. (1988). Influence
of bolus volume on swallow-induced hyoid movement in normal subjects. American Journal of
Roentgenology, 150, 1307-1309
 Donzelli, J., & Brady, S. (2004). The effects of breath-holding on vocal fold adduction:
Implications for safe swallowing. Archives of Otolaryngology—Head and Neck Surgery, 130, 208-
210
 Fujiu, M., & Logemann, J. A. (1996). Effect of a tongue holding maneuver on posterior
pharyngeal wall movement during deglutition. American Journal of Speech-Language Pathology,
5, 23-30
 Hind, J.A., Nicosia, M.A., Roecker, E.B., Carnes, M.L., & Robbins, J. (2001). Comparison of
effortful and noneffortful swallows in healthy middle-aged and older adults. Archives of Physical
Medicine and Rehabilitation, 82, 1661-1665
 Huckabee, M.L., Butler, S.G., Barclay, M., & Jit, S. (2005). Submental surface electromyographic
measurement and pharyngeal pressures during normal and effortful swallowing. Archives of
Physical Medicine and Rehabilitation, 86, 2144-2149

68
 Junko, S., Yasushi, F., & Tsutomu, N. (2006). Processes of recovering swallowing function after
supraglottic or supracricoid laryngectomy. Otologia Fukuoka, 52, S53-S58
 Lazarus, C. L., Logemann, J. A., Song, C. W., Rademaker, A. W., & Kahrilas, P. J. (2002). Effects of
voluntary maneuvers on tongue base function for swallowing. Folia Phoniatrica et Logopaedica, 54,
171-176
 Logemann, J. A., Pauloski, B. R., Rademaker, A. W., & Colangelo, L. A. (1997). Super-supraglottic
swallow in irradiated head and neck cancer patients. Head and Neck, 19, 535-540
 Martin, B. J. W., Logemann, J. A., Shaker, R., & Dodds, W. J. (1993). Normal laryngeal valving
patterns during three breath-hold maneuvers: A pilot investigation. Dysphagia, 8, 11-20
 Ohmae, Y., Logemann, J. A., Kaiser, P., Hanson, D. G., & Kahrilas, P. J. (1996). Effects of two
breath-holding maneuvers on oropharyngeal swallow. Annals of Otology, Rhinology and Laryngol,
105, 123-131
 Topaloglu, I., Kocak, I., & Salturk, Z. (2012). Multidimensional evaluation of vocal function after
supracricoid laryngectomy with cricohyoidopexy. Annals of Otology, Rhinology, and Laryngology, 121,
407-412
 Topaloglu, I., Koprucu, G., Bal, M. (2012). Analysis of swallowing function after supracricoid
laryngectomy with cricohyoidopexy. Otolaryngology—Head and Neck Surgery, 146, 412-418
 Van Daele, D. J., McCulloch, T. M., Palmer, P. M., & Langmore, S. E. (2005). Timing of glottic closure
during swallowing: A combined electromyographic and endoscopic analysis. Annals of Otology,
Rhinology, & Laryngology, 114, 478-487
 Webster, K. T., Samlan, R. A., Jones, B., Bunton, K., & Tufano, R. P.
 (2010). Supracricoid partial laryngectomy: Swallowing, voice, and speech outcomes. Annals of
Otology, Rhinology, & Laryngology, 119, 10-16
 Yace, I., Cagli, S., Bayram, A., Karasu, F., Sati, I., & Ganey, E. (2009). The effect of arytenoid
resection on functional results of cricohyoidopexy. Otolaryngology—Head and Neck Surgery, 141,
272-275

69
 ASHA 2012 – Atlanta, GA
The importance of seeing the orchard for the peaches!
Vicki Lewis, M.A., CCC-SLP
70
 59 year old male presented to Otolaryngology in July
2011 for further evaluation of chronic dysphagia
 Patient recalled having an NGT placed during
hospitalization for lung abscess in 2002 and reported
that he feels that he has experienced difficulty
swallowing since that time
 Taking a regular consistency diet with thin liquids
 Patient describes that he has the most difficulty
swallowing solids
 Denies weight loss /
pneumonia

71
 Bilateral lung abscesses – treated
surgically in 1991 & 2002

 No history of cervical spine surgery or

neurological events or diseases

72
 Videofluoroscopic Swallow Study - July 2010
reportedly showed: “moderate-severe pharyngeal
stasis after the swallow. There appeared to be
limited passage of the bolus into the esophagus
and penetration of all consistencies was noted
after the swallow to the level of the TVFs.
Penetration cleared with a cued throat clear.”
 Diet recommended: Non oral means of nutrition
with limited p.o. trials of puree and thin liquids
(Pt. reported that he was unaware of these
findings / recommendations)
 The Radiologist recommended a CT scan of the
neck with contrast
73
 CT Scan of the neck in July 2010 was
remarkable for asymmetry of the
submandibular glands, but they appeared fairly
normal in configuration and large anterior
cervical osteophytes involving C4-C6.
Appearance of the larynx and pharynx were
grossly normal.

 EGD in Aug. 2010 was normal

74
75
 Enlargement of bilateral styloid processes
demonstrated

 Enlargement of the hyoid bone with

pseudoarticulation to the bilateral superior
cornu of the thyroid cartilage which deforms the
right posterior pharyngeal mucosa at the level
of the epiglottis

 Impressions: Eagle Syndrome

76
77
 In 1937, Dr. Watt W. Eagle described a set of
symptoms that occur secondary to elongation of
the styloid process (this was first noted by an
Italian surgeon in 1652). Normal length of the
styloid process is 2.5 to 3 cm. Symptoms
include:
- Facial pain - Neck pain on rotation*
- Ear pain - Tongue pain
- Dysphagia* - Submandibular swelling
- Globus sensation*
- Hypersalivation*
- Change in vocal quality*
References: #3, 4, 5

78
 INCIDENCE ETIOLOGY
In the general population 4 Post tonsillectomy
– 7% of people have an Neck trauma
elongated styloid process

Of those individuals (4 - 7%
of the population) , 4 –
10.3% experience
symptoms / pain

References: #2, 5 & 6

79
 OPTIONS
 Non surgical option –
nonsteroidal and steroidal
anti-inflamatory
medications and/or
injection of anesthetics in
the area of the ligament
insertion
 Surgery: Transoral approach
 Surgery: Cervical approach
Reference: # 1 & 5
OUR SURGEON’S PLAN
 Neck exploration and
disarticulation of the
stylohoid attachment
 Surgery put on hold, in
obtaining clearance by
Cardiology for the
surgery, pt required
cardiac stent placement
80
 Neck exploration with bilateral
stylohyoid ligament and bone
resection
 A horizontal incision was made at
the level of the hyoid. Suprahyoid muscle bridge
located centrally was left intact. Dissection was
completed lateral to the central segment of the hyoid
 Approximately 15 mm of ossified stylohyoid ligament
was removed bilaterally beginning at its insertion to
the lesser cornu of the hyoid bone.
 Dobhoff feeding tube was placed 81
82
 MBS on POD-1:  PEG placed - POD-3
 Observed two swallows  Medical complications
of puree consistency (GI) patient required 7
 Penetration to the level day hospitalization
of the TVF before,
during, and after the
swallow with no
reflexive cough / throat
clear
 No change from
previous examination
 PEG recommended

83
 Laryngeal Elevation

 Pharyngeal Constriction

 BOT retraction (?)

 Did not recommend Shaker Exercise

84
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86
87
 The importance of knowing the etiology of dysphagia –
Leave no stone unturned!
 Can have a huge impact on timing and type of
treatment
 Collaboration
 Sometimes things can be out of the ordinary – look for
a zebra in a herd of horses!

88
1. Hossein, R, Kambiz, M, Mohammad, D, Mina, N. Complete
recovery after an intraoral approach for eagle syndrome.
The Journal of Craniofacial Surgery 2010; 21(1): 275-276.
2. Klecha, A, Hafian, H, Devauchelle, B, Lefevre, B. A report of
post-traumatic eagle’s syndrome. Int J Oral Maxillofac Surg
2008; 37; 970-972.
3. Kim, E, Hansen, K., Frizzi J. Eagle syndrome: case report
and review of the literature. Ear Nose & Throat Journal
2008; 87(11): 631-633.
4. Murtagh, R, Caracciolo, J, Fernandez, G. CT findings
associated with eagle syndrome. Am J Neuroradiol 2001;
22¨1401-1402.
5. Pagani D, Capaccio P, Balzani A, Pignataro, L. Dysphagia
and submandibular swelling. J Am Dent Assoc 2010; 141;
1089-1093.
6. Restrepo, S, Palacios, E, Rojas, R. Eagle’s syndrome. Ear,
Nose & Throat Journal 2002; 81(10): 700-701.
89
 Bernice K. Klaben, Ph.D. CCC-SLP BRS-S
University of Cincinnati
Department of Otolaryngology Head and Neck
Surgery

90
 88 yr old male
 History of
 Myasthenia gravis diagnosed at age 60
 COPD
 CHF
 Dysphagia (onset of repeated pneumonia since 2/10)
 Childhood polio
 SN Hearing Loss
 Arthritis
 High blood pressure
 Difficulty swallowing
 Bronchiectasis

91
 Left hip replacement

 Skin cancer removals

 Gall bladder removed

 Thymectomy 1992

 Hernia repair

 Cataract surgery

92
 What is it?
 Chronic autoimmune neuromuscular disease
characterized by varying degrees of weakness of
the skeletal (voluntary) muscles of the body. First
described in 1672 by Oxford physician, Thomas
Willis.

 Causes
 Antibodies block, alter, or destroy acetylcholine
receptors (AChR) at the neuromuscular junction
preventing muscle contraction from occurring.
These antibodies are produced by the body’s
own immune system.

93
 Symptoms may vary in type and severity
 My involve weakness of the eye muscles,
unstable gait, dysphagia, shortness of breath,
dysarthria and weakness in the arms, hands,
fingers legs and neck.

 Can generally be controlled with medications,

removal of the thymus gland, and sometimes
goes into remission (either temporary or
permanently).
94
 Pt referred by neurologist secondary recurrent aspiration
pneumonias (last hospitalization 5/2011) - 6 bouts of
pneumonia since 2008 requiring hospitalizations and
recovery in NH)

 MG – fairly well controlled

 Pt denied any chewing, swallowing or breathing problems

 Uses walker and walks 200 yds each day and follows an
exercise program

 Alone during the day but lives with daughter

95
 Gait is slightly unsteady with a wide base
and forward flexed posture

 Reported planter flexor muscle weakness

 Risk for falls secondary to balance

96
 Pt reported:
 Takes longer to eat
 Coughs when drinks liquids
 Feels he is swallowing a huge amount of food
 Decrease sensation right jaw area – from shrapnel
injury WWII
 Has seasonal allergies with increased phlegm

 Pt’s daughter reported any illness progresses quickly to

pneumonia

 Eating soft, moist foods with honey thickened liquids,

avoiding hard, dry and tough to chew foods

97
 1/2010 – MBS revealed trace penetration with
thin barium and worse with a straw. No
penetration or aspiration with nectar thick
liquids, mixed consistency or barium coated
graham cracker

 Pt received dysphagia therapy in nursing home

 4/2010 – MBS showed minimal flash

penetration of thin liquid without aspiration. No
dietary restrictions

98
 5/2010 – daughter concerned as speech pathologist
was giving “electrical stimulation on neck muscles” and
wanted to know what neurologist thought.

 Pt sleeping with head of bed elevated

 5/2010 – MBS revealed direct aspiration on thin and

nectar liquids.

 Honey thick liquids with chin tuck

 No straws
 Mechanical soft diet
 Alternate liquids and solids
 Double swallows 99
 OroMotor Examinaiton:
 Labial – moderately reduced – food ran out of both sides of
mouth
 Lingual – mildly reduced ROM, moderately reduced tongue
strength
 Velo-pharyngeal Fx: Mildly reduced posterior pharyngeal
movement
 Dentition: Upper dentures, lower partials – good fit
 Facial: Decreased sensation at mandibular branch of CNVII
 Laryngeal elevation/Tilt: Mildly delayed, moderately decreased
laryngeal excursion
 Cough: sometimes productive
 Secretions: poor oral containment
 Voice: occasionally wet vocal quality

100
 Base of tongue movement mildly reduced L>R

 Pharyngeal and longitudinal constrictors

moderately reduced during sustained high “e”

 Moderate bowing of TVFs

 Occasional asymmetry of the arytenoids (R moved

before L)

 Able to breath hold

 Epiglottis inverted and retroverted with dry swallow

101
 Mild pooling in valleculae and pyriforms on all
consistencies

 Penetration and aspiration on honey thick

liquids, applesauce, mixed consistencies using
effortful swallow and/or chin tuck

 Super supra-glottic swallow revealed no

penetration or aspiration on nectar thickened
liquids, applesauce, pudding, peaches,
crackers or pretzels. Pt did aspirate on thin
using this technique

102
103
104
 Techniques
 Tongue hold and swallow
 Mendelsohn maneuver
 Super supra glottic swallow
 Cough/swallow to clear “wet sounding voice”
 Suck- swallow
 Tongue lateralization exercises
 Lip closure techniques
 Thermal tactile stimulation
 Glide up and down the scale
 Sustain ah at comfort, comfort high and
comfort low pitches 105
 Oromotor examination:
 Labial – Mildly reduced – thin liquids secreted
from R side
 Lingual -decreased strength, improved ROM
 Velo-pharyngeal FX: WNL
 Dentition: upper denture and lower partials
 Facial: Reduced sensation on the R
 Laryngeal Elevation/Tilt: delayed and reduced
 Cough: weak but productive
 Secretions: Oral containment issues reported
and occasionally noted

106
 Reduced pharyngeal and longitudinal constriction on
sustained high ‘e’

 Moderate bilateral TVF bowing

 Occasional asymmetry of the arytenoids (R moving

before L)

 Epiglottis noted to invert and retrovert with bolus

 Performed breath hold successfully

 Super supra-glottic swallow technique worked the best for

all consistencies. Effortful swallow was not effective.

 Recommended pt continue with dysphagia

107
108
 Pt did not have any pneumonia or
hospitalizations for 6 mos following the
swallowing techniques on daily basis

 Pt very compliant with following eating

precautions and using techniques

 Pt fell in Feb 2012 and suffered a compression

facture in the lower back with increased pain.

109
 Little research on dysphagia therapy and MG

 Treatment techniques – no new pneumonias

for 6 mos.

 Individually assess each pt and find best

technique(s) based on examinations as well as
what is in the literature

 Respect pt’s wishes

110
 Colton-Hudson, A., Koopman, W.J., Moosa, T., Smith, D., Bach,
D., Nicolle, M., A prospective assessment of the characteristics of
dysphagia in myasthenia gravis. Dysphagia, 2002;17: 147-151.
 McIntyre, K., McVaugh-Smock, S., Mourad, O. An adult patient
with new-onset dysphagia. Canadian Medical Association, Journal,
2006;175:1203-1205.
 Myasthenia gavis. The Lancet, 2001;357:2122-2128.
 Myasthenia Gravis Foundation of America, Inc.
http://www.myasthnia.org
 Scheer, B.v., Valero-Burgos, E., Costa, R. Myasthenia gravis and
endurance exercise, 2012;91:725-727.
 Teramoto, K., Kuwabara, M. & Matsubara, Y. Respiratory failure
due to vocal cord paraesis in myasthenia gravis. Respiration,
2002;69:280-282.
 National Institute of Neurological Disorders and Stroke,
myasthenia gravis http://www.ninds.nih.gov/disorders

111
Linda Stachowiak MS/CCCSLP BRS-S
MD Anderson Cancer Center
Orlando

112
 63 yr. old with hx of nasopharyngeal carcinoma in
1992 treated with concurrent chemoradiation

 Followed by a new diagnosis of a T4N0M0 SCCA

of the left base of tongue treated with:

 induction chemotherapy completed 7/8/11

 followed by external beam radiation completed 11/28/11

 followed by interstitial brachytherapy implants completed

12/5/11

113
 Patient has lost
45 lbs. to date
despite the use of
nutritional
supplements

114
 Patient has mild oral deficits and moderate-
severe pharyngeal deficits

 Cough, re-swallow technique ineffective on all

consistencies

 Chin tuck ineffective on all consistencies

 Supraglottic swallow not effective in

eliminating aspiration on all consistencies
115
 Option A: continue with the “safest” PO in
light of the fact that the patient has not
developed an aspiration pneumonia to date

 Option B: Recommend NPO for now until

patient receives cancer treatment, then
reassess

116
 Option A: continue with the “safest” PO in
light of the fact that the patient has not
developed as aspiration pneumonia to date

 Option B: Recommend NPO for now until

patient receives cancer treatment, then
reassess ….PEG placed

117
 Significant weight loss at the onset of cancer treatment

 No effective strategies to eliminate aspiration

 Patient about to START treatment. Want the patient to

get through treatment without developing an aspiration
pneumonia which could potentially cause a break in
treatment.

 Aspiration is an “opportunistic” infection – patient may

be more prone to develop during upcoming induction
chemotherapy when immunocompromised

118
 Scenario #1- after entire course of
therapy

 Scenario #2- after the first course of

therapy, which in this case is induction
chemotherapy

119
 Scenario #1- after entire course of therapy

 Scenario #2- after the first course of

therapy, which in this case is induction
chemotherapy

 Always hopeful that we can get patient to

take some PO intake, even if only small
amounts safely for pleasure to prevent
disuse atrophy
120
 Overall deficits are not
much better/worse,
BUT
patient’s ability to
implement successful
strategies is – patient
can now protect the
airway more efficiently

121
 Patient understand the risk of not using the
strategy

 Patient has adapted/accepted the need to

utilize the airway protection strategy

 Patient has good cognition/good motivation

 Patient has good sensation-would rather do the

technique then cough violently

122
 My thought was to re-evaluate when I suspect
some change in status:

 We know the swallowing status will deteriorate or improve

at different intervals of treatment

 Work closely with the patient/family (educate them on the

s/s of aspiration so they may contact you to trigger a re-
eval when they notice a change in swallowing status)

 Work closely with the “team” (patient begins to have more

“lung congestion”, patient admitted with pneumonia,
please re-refer)

123
 Patient has insurance issues, lost to
follow-up

 PEG dislodges- patient does not

want it replaced…this triggers a re-
referral/MBS with Speech Pathology

124
 MBS results not
much different than
previous MBS

 Cancer treatment is
completed

 Patient is NED (no

evidence of disease)

125
Deficit Observed:
Hypoglossal out on right/tongue
weakness
No palatal elevation-post XRT
changes from NPC treatment
earlier
Absent epiglottic
inversion/aspiration
What can I offer this
deficit?
Placement of food
Tongue exercises not felt to be
effective with cranial nerve damage
from tumor
Nosey cup to reduce need for head
flexion backwards
Supraglottic Swallow Maneuver
126
Deficit Observed: What can I offer this
deficit?
Ill-fitting dentures Realignment/new dentures

Decreased BOT Masako Maneuver-limited by

retraction/decreased tongue mass hypoglossal n. injury

Reduced hyolaryngeal elevation Shaker, Mendelsohn, falsetto

Oral stasis Liquid wash

127
 Jeri A. Logemann, Ph.D., CCC-SLP, BRS-S
Ralph and Jean Sundin Professor
Departments of Communication Sciences and
Disorders, Otolaryngology, and Neurology
Northwestern University
Evanston and Chicago, Illinois

128
 77 Years old

• Gall bladder removed 1/2012

• Post-op pneumonia – Aspiration
• PEG
• Acute respiratory failure
• Intubations
• Trach in March removed 3 weeks before MBS
• Patient in Nursing home
129
2 previous MBS elsewhere (rec: non oral)

Current MBS: 2 swallows each of

1ml, 3ml, 5ml, 10ml, Cup – Thin Liquid

5ml, 10ml, Cup – Nectar Thick Liquid

3ml Pureed

¼ Lorna Doone cookie

Head rotation, Mild effortful swallow

130
Oral feeding on Nectar Thick Liquid

Head rotated left – slightly effortful swallow

Therapy: Base of Tongue Exercises

Laryngeal Elevation Exercises

131
Boluses given (2 of each)

Thin liquids: 1ml, 3ml, 5ml, 10ml, Cup

Pureed: 3ml

Masticated: ¼ Lorna Doone Cookie

132
VISIT 1 VISIT 2

133
Full oral intake (care with dry foods or tough
meat)

Eliminate PEG

No further pneumonias

134