* Modified Barium Swallow - May 2003
GE: 53 SEX: F DOB: 10/18/49
MODIFIED BARIUM SWALLOW EVALUATION
Cape Cod Hospital - Hyannis, MA 02701
Ord Phys: MUCCI, M.D., STEVEN
DIAGNOSIS: DYSPHAGIA MEDICAL HISTORY: PATIENT IS A 53 YEAR OLD FEMALE WHO UNDERWENT A NECK LIFT TWO YEARS AGO IN INDIANA. SHE HAS COMPLAINED OF CHRONIC DYSPHAGIA SINCE THAT TIME. SHE HAS SPONTANEOUSLY LEARNED THAT A CHIN TUCK AND/OR A HEAD TURN IMPROVE HER SWALLOWING FUNCTION. SHE ALSO FEELS SHE NEEDS TO KEEP A HEAD DOWN POSTURE IN ORDER TO MAINTAIN A FULL AND OPEN AIRWAY. PROCEDURE -
Oral and pharyngeal phases are observed under Video Fluoroscopy.
ORAL PREPARATORY PHASE This patient showed:
Normal control and bolus transit: Efficient oral motility and bolus formation; no oral residue; mastication is brisk and thorough.
REFLEX INITIATION PHASE This patient showed: ANATOMY:Normal: reflex initiated at the back or base of tongue above the epiglottis. TIMING: Normal: no hesitation; smooth and continuous motility from posterior tongue into pharynx.
PHARYNGEAL PHASE (Pharyngeal - Laryngeal, Cricopharyngeal) This patient showed: Limited laryngeal excursion; epiglottis may achieve horizontal position, but fails to invert fully; a laryngeal vestibule gap may be seen during the swallow (continuously or occasionally) . Epiglottic recoil after the swallow also appeared to be slow.
PHARYNGEAL CLEARANCE (PERISTALSIS) This patient showed: Mild residue: (<10%) of a small bolus remains in the mid and /or lower No Aspiration, 2 swallows to clear No Aspiration spontaneous SG swallow No Aspiration No Aspiration
Premature spill and penetration Intermittent penetration No penetration Unable/reverts to chin tuck No Aspiration, Mild Pooling pharynx after the first swallow.
ASPIRATION This patient showed: The patient does demonstrate episodes of laryngeal penetration which did not go below the level of the vocal cords. This can be eliminated with a chin tuck maneuver. The patient also notes that a head turn eliminates this. This was viewed in the AP position. Penetration appears due to loss of control of the bolus at the tongue base with premature spillage. There were also spontaneous uses of the Mendelsohn maneuver and supraglottic swallows on different trials. Both of these are compensation techniques that the patient has obviously learned through trial and error. No aspiration today.
SUMMARY AND IMPRESSION: The patient is a 53 year old female who two years ago underwent a face and neck lift. She complains of dysphagia which is seen on today’s examination as a pharyngeal phase dysphagia. An oral peripheral evaluation prior to the MBS study revealed normal lingual motility in the oral cavity. However, WHEN THE PATIENT IS ASKED TO PROTRUDE HER TONGUE AND MOVE HER NECK AND HEAD FROM A NEUTRAL TO AN EXTENDED POSITION, THE TONGUE RETRACTS ABNORMALLY. THIS APPEARS DUE TO AN ANCHORINIG EFFECT PERHAPS SECONDARY TO SURGICAL PROCEDURE.On imaging the swallow appears normal in the oral phase. There is some premature bolus loss due to reduced tongue base control. This occurs with thin liquids and results in premature spillage into the pharynx with laryngeal penetration on thin liquids when taken in the head neutral position. This is eliminated with the use of a chin tuck. The patient also has demonstrated spontaneous use of a supraglottic swallow. She also on occasion uses the Mendelsohn maneuver to maintain upper esophageal sphincter opening during prolonged sips via straw, etc. However, these activities do result in occasional episodes of laryngeal penetration. There is no aspiration today. ETIOLOGY OF THE DYSPHAGIA COULD CERRTAINLY BE DUE TO HER POST SURGICL STATUS..
MARIA DEPASQUALE MS CCC-SLP
SPEECH-LANGUAGE PATHOLOGIST
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