Spring quarter (fondly known among my classmates as “the quarter that broke our souls”) is finally over. Final case summaries have been printed and signed, ART meetings are done, and finals have been…well…taken (I wouldn’t go so far as to say “aced”). Among other things, we took the class that all grad students anticipate with bated breath: dysphagia. Ok, ok, in all fairness, swallowing disorders are a huge part of the field, but I can’t say that many students are jumping up and down to memorize the neural innervation for the muscles of mastication or characteristics of aspiration pneumonia.
Can you keep a secret? Yeah, I didn’t think so. But…I’ll tell you anyway, since I’m not sure how else to keep this post going. Despite my initial doubt, I was shocked to realize that I kind of sort of actually might have liked dysphagia. I attribute 79.24% of this to the sheer brilliance and power of our professor, Dr. Bob Miller, though there’s was a solid 20.76% that actually came from pure, unadulterated interest in this facet of the field. Don’t get me wrong, I’m still a ped’s girl through and through (and this wasn’t our pediatric dysphagia class), but the lectures got me hooked much like a Costa Rican soap opera: will Mr. Smith clear the thin liquids once they penetrate the larynx, or will he aspirate and and up with yet another bout of pneumonia? Does Mrs. Johnson have a stroke of the posterior inferior cerebellar artery, or could her inability to swallow be part of a darker, more disturbing conversion disorder brought on by the stress of watching her long lost brother find out about her grandmother’s uncle’s niece’s illegitimate child?
Anywho, since I just had to prove myself “worthy” through a somewhat horrific dysphagia final, I thought I would test all of you SLPs out there to see how sharp your assessment and diagnostic skills are these days. May the odds be ever in your favor:
1. Mr. Hughes comes to you complaining of severe chest pain that occurs frequently during swallowing. He says that solids tend to “stick in his throat” during meal times, but that liquids seem to clear easily. This patient likely has difficulty with which stage of swallowing? (oral, early pharyngeal, middle pharyngeal, late pharyngeal, esophageal). What is one likely explanation for his complaints?
2. If your patient has a hyperactive gag reflux (and other hyperactive reflexes), what kind of lesion does he/she likely have? (unilateral lower motor neuron, bilateral lower motor neuron, unilateral upper motor neuron, bilateral upper motor neuron)
3. Individuals with severe ataxia may experience nasal regurgitation during meals. Why?
4. What esophageal condition causes a “bird beak” or “funnel-like” appearance of the esophagus during imaging?
5. ________________(hot food/liquid OR cold food/liquid) can be a catalyst for esophageal spasms in someone with a history of esophageal spasms.
6. Explain the rationale behind the free water protocol.
- Esophageal phase; esophageal achalasia or possible esophageal spasms
- bilateral upper motor neuron lesion
- These patients may have difficulty coordinating the raising and lowering of their velum during their swallow, so they may not achieve velo-pharyngeal closure at the right time during the pharyngeal phase of the swallow
- Esophageal achalasia
- Cold foods/liquids
- Oral hygiene is one of the biggest concerns for patients at risk for aspiration, since the cause of aspirational pneumonia is the bacteria that gets aspirated with the food/liquid and not the food/liquid itself. For some patients who are on thickened diets or are NPO in the hospital, it may be alright to allow them water to thirst, but only if there is extremely special attention paid to their oral hygiene. Even if they do aspirate small amounts of water, their lungs can reabsorb the water and there isn’t a great risk of developing bacterial pneumonia since so much care has been taken to maintain good oral hygiene.