Rebecca Ciafre & Laura Nygard

Case History:
Patient is an 86-year-old man with a hx of chronic heart failure and chronic cough. His lungs were x-
rayed on 11/13/15 and were determined to be clear. This appointment is to rule out possible
dysphagia/aspiration as the cause of cough. The patient is currently on antibiotics and a steroid to address
possible infection that is causing him to cough. Patient and his wife state that he has been coughing
intermittently since 2007. He c/o increased mucus and shortness of breath post-coughing. He was seen for
a swallowing evaluation in 2014. The result of the exam indicated that the patient had trace aspiration
with larger sips of thin liquid secondary to slow airway closing and aspiration of residual. Significant
vallecular residue noted, increased with viscosity. At the time, a chin tuck, double swallowing, and
alternating liquids and solids were recommended. When asked, the patient stated that he has not been
following these recommendations. Dysphagia treatment was recommended at that time, which he
declined. However, his symptoms have worsened presently and his swallow will be re-examined. He c/o
coughing spells at night while is both sitting up and laying down He is currently not on any reflux
medications and denies having reflux. Voice is wet intermittently. When requested to clear, voice quality
is WFL although mildly weak.

Trials:
The patient was alert and upright for the duration of the study. The patient was presented with 5m; thin,
10ml thin, cup sip thin, 5ml nectar, cup sip nectar, puree (applesauce), think liquid wash, mechanical soft
(rice krispie), solid cracker and a barium tablet.

Anatomy: At rest, anatomy appears within normal limits.

MBS Report:
Oral Stage: Functional. Patient presented with adequate oral physiology, including tongue movement and
bolus hold. Mild residue was consistently present on base of tongue across trials, but was cleared with
subsequent swallows. Mastication during solid trials is within normal limits.

Pharyngeal Stage: Moderately impaired. Initiation of pharyngeal swallow occurs at the level of the
vallecula for all trials. Anterior hyoid excursion is timely, despite the delayed epiglottic inversion and
airway closure. Delayed epiglottic inversion is due to slow movement. This causes poor airway closure,
resulting in penetration across several liquid consistencies. Aspiration occurred during thin liquid wash
followed by coughing, due to poor laryngeal closure and slowed epiglottic inversion.

Pharyngeal and tongue base squeeze are severely reduced resulting in no movement of the posterior
pharyngeal wall and decreased movement of the tongue base. This results in moderate to severe vallecular
residue, characterized by less than half the bolus. As viscosity increases, vallecular residue increases; the
most severe residue occurs during puree trials, when more than half the bolus remains. Mild to moderate
pyriform residue is noted across trials, worsening as viscosity increases. Sequential swallows slightly
decrease amount of vallecular residue and often clear pyriform residue to trace amounts. PES opening is
within normal limits.

A chin tuck with subsequent coughs and sequential swallows was implemented on thin liquid trials in an
attempt to widen the vallecula and protect the airway. During chin tuck trials, no significant
improvements were noted. The only time aspiration occurred was during a thin wash trial with a chin
tuck. A chin tuck, breath hold, and second swallow technique was implemented simultaneously during a
thin liquid trial, when used appropriately, this is a successful strategy. However, due to lack of
compliance in the past the patient may not be able to follow through with this recommendation. The
second swallow cleared the pyriform residue to trace amounts. During the last thin liquid trial, a breath
hold and head turn was implemented, increasing airway closure and decreasing overall pharyngeal
 Rebecca Ciafre & Laura Nygard

residue. A head turn with a second swallow is implemented during puree, mechanical soft, and solid
trials. All trials resulted in moderate vallecular residue, trace pyriform residue, and no penetration.

Esophageal Phase: No signs of impairment. No concerns at this time.

Assessment:
Patient presents with mild-moderate oropharyngeal dysphagia, characterized by penetration and
pharyngeal residue. The following recommendations are safe for therapeutic purposes. Fatigue is likely
due to the rigorous demands of the compensatory strategies. If weight loss becomes a concern due to
insufficient oral nutrition, alternative feeding methods may need to be addressed. Patient is an appropriate
candidate for rehabilitation.

Patient is safe for thin liquids under the following recommendations:

1.   Small amounts of liquids (no more than one cup sip at a time)
2.   Utilize a breath hold and left head turn for all thin liquids
3.   Initiate at least one dry swallow after every trial, before turning head to neutral position

Patient is safe for solid consistencies under the following recommendations:

1.   Small bites with thorough chewing
2.   Utilize a left head turn for all trials
3.   Initiate at least one dry swallow after every trial before turning head to neutral position

Long Term Goals:

1.   The patient will consume a regular diet with reduced reliance on compensatory strategies and
without s/s of penetration and aspiration.
2.   The patient will maintain nutrition/hydration via oral means.

Short Term Goals:

1.   Patient will improve pharyngeal squeeze to decrease amount of pharyngeal residue, therefore
decreasing risk of residual penetration and aspiration.
•   Objective 1: Patient will limit bolus size to 1 tsp. without cues on 90% of trials.
•   Objective 2: Patient will implement head turn to the left for all oral boluses without cues on
100% of trials
•   Objective 3: Patient will initiate a second swallow for all oral boluses without cues on
100% of trials.
•   Objective 4: Patient will complete 30 effortful swallows 3x/day, 5x/week.

2.   Patient will improve airway closure to reduce risk of aspiration.

•   Objective 1: Patient will implement breath hold during all thin-liquid trials without cues on
100% of trials.
•   Objective 2: Patient will maintain laryngeal elevation for 3 seconds during execution of
Mendelsohn Maneuver over 15 repetitions 3x/day, 5 days/week.
•   Objective 3: Patient will complete Shaker exercise with three 30 second head holds and 30
up/down repetitions while lying flat at 180 degrees 2x/day, 5 days/week.