Monday, January 02, 2006

My 4th. Modified Barium Video Swallow X-ray Study in 8 yrs.

Date: June 15, 2005 Medical Diagnosis: Post Polio
Reason for referral: Coughing, Possible Aspiration, Bronchiectasis
View Assessed: Lateral & AP, Radiologist, and Speech Language Pathologist

Oral Preparatory Phase:
Consistencies presented:
  • Thin liquid from teaspoon and from cup in lateral and AP views.
  • Spillage from the Lips: None

  • Impaired Bolus Formation; None

  • Difficulty with chewing: None

  • Spillage into pharynx: yes

Oral Phase:
  • Hesitation: None

  • Tonque thrust: None

  • Repetitive tongue pumping: None

  • Slow oral thrust: Doesn’t try to swallow cookie without liquid

  • Tongue Weakness: Yes, base is very weak

  • Incomplete/lack of Velopharyngeal closure: None

  • Piecemeal deglutition: Yes

  • Oral Residue: Not significant

Pharyngeal Phase
  • Delayed Swallow: Yes at times

  • Absent swallow: None

  • Incomplete/lack of epiglotic inversion: Yes, Very minimal inversion

  • Reduced laryngeal elevation: None

  • Aspiration: None

  • Impaired UES opening: Yes, same as last MBS post myotomy.

  • Vallecular residue: None, as so little inversion of epiglottis

  • Priform sinus residue: Yes, major, everything, even liquid

  • Pharyngeal wall residue: Yes, minor

  • Reduced pharyngeal peristalsis: Yes

  • Asysmmetric Bolus flow: Yes; down Right side. This may be new.

  • Multiple swallows per bolus: Yes 4 to 5.

  • Dynophagia: None

Anatomical Structures
  • Cervical osteophytes: None

  • Curled Epiglottis: None

  • Cricopharygneal bar: Cricopharyngeus is prominent

  • Zenkers Diverticulum: Yes; as on last study in 2003

  • Tracheo-esophageal fistula: None

Esophageal Phase
Radiologist reported primary esophageal peritalis in 2003

Clinical Impression:
Area of Dysphagia: oral phase, pharyngeal phase, moderate to severe.

  • Oral motor exam reveals slight weakness of left nasolibia fold, not new according to patient and slightly reduced right side velar retraction as compared to the left side but excellent range.

  • Vocal quality is slightly wet.

  • He reports biting tongue, cheek and lips both on right and left sides.

  • Speech is mildly hypernasal.

  • Left lip weakness on retraction.

  • Dry mouth from medications and tonque. Very dry. He says he does not drink enough water but he does use constantly as a liquid wash down when eating.

  • Frequent spontaneous coughing reportedly due to bronchiectasis.

  • Healthy teeth.

Swallowing Recommendations:
  • Small amounts per swallow(1/2 tsp)

  • Sitting upright at 90 degrees during meals

  • Remain upright for 20 to 30 minutes following meals.

  • Alternate solid and liquid swallows.

  • Add extra moisteners to solid textures (eg. Gravy, sauces, sour cream, mayonese, etc)

  • Ensure no food is left in mouth at the end of a meal

  • Maintain good oral hygiene.

  • Allow 4 to 5 multiple swallows.

  • When compared with the last MBS of Feb 26, 2003, there is no significant change other than possibly the right preferential flow of liquid on AP view.

  • Pharyngeal stasist evidence of tight cricopharygneus and weak tongue base appear unchanged, however the patient says swallow is more work, more nasal regurgitation, more likely breathing is more difficult with bronchiectasis.

  • Patient believes bronchiectasis is caused by aspiration of food though he says Dr McKim did not agree.

  • Given that the patient is now more amenable to the idea of PEG, and he has reported slight weight loss over 11 years, PEG may be appropriate.

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