Videofluoroscopy case 1

I've been starting to analyse videofluoroscopies as part of my dysphagia competency program and thought it would be usefull to compare my observations to the structured reports patients are given. Here goes no. 1.

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My observations

Clinical Report

Solids Delayed swallow trigger, residue in the valleculae, able to clear residue with a cough, decreased sensation? Fluids Tipped back – decreased oral control, delayed swallow trigger, residue in valleculae, penetration, able to clear residue with a second swallow Summary Oral stage – reduced coordination of chewing and reduced base of tongue to pharyngeal wall approximation. Pharyngeal stage – delayed swallow trigger, significant valleculae residue, penetration but no aspiration.

Oral Phase: Lip closure was slightly reduced resulting in mild lip spillage. Tongue control was adequate for cohesive bolus formation and for oral to pharyngeal transfer. Tongue function was slightly reduced resulting in mild oral residue, piecemeal oral clearance and, on fluids, premature spillage into the pharynx to the level of valleculae sinus. Chewing was slightly reduced due to reduced jaw movement and tongue weakness with decreased range of movement. Palatal elevation was adequate resulting in complete velopharyngeal seal. Pharyngeal Phase: Initiation of the swallow reflex occurred when the bolus reached the level of the valleculae. This was considered to be slightly delayed. Base of tongue to posterior pharyngeal wall approximation was reduced resulting in poor bolus propulsion through the pharynx.  There was subsequent mild base of tongue and valleculae residue post swallow. There was evidence that clearing soft and normal diet residue from the valleculae was more effortful than clearing yogurt; indicated by facial expression, reported feeling of the bolus sticking and effortful swallow, also cough triggered in response to normal bolus, although there was no evident penetration/aspiration. Hyolaryngeal excursion was adequate to facilitate epiglottic to arytenoid closure and upper oesophageal sphincter opening. Pharyngeal contraction was slightly reduced resulting in mild valleculae residue after the swallow. There was no evidence of aspiration during the study. There was trace penetration of the laryngeal vestibule above the level of the vocal cords with normal fluids but no penetration into the subglottic space. The trace penetration of thin fluids was cleared on the initial swallow. There was no penetration of the laryngeal vestibule with food, although a clearing cough was triggered on normal bolus. Compensatory Techniques: The following strategies were trialed with thin fluids: Multiple spontaneous swallows were effective to clear base of tongue and valleculae residue. Prompted smaller sips were beneficial to achieve less effortful swallow.

SUMMARY

Mrs …….. presented with mild oral phase dysphagia characterized predominantly by:

• Slightly reduced tongue function.

There was mild to moderate pharyngeal phase dysphagia characterised by:

• Delayed initiation of the swallow reflex
• Reduced base of tongue to posterior pharyngeal wall approximation and reduced pharyngeal contraction resulting in:

• poor bolus propulsion through the pharynx
• mild base of tongue and valleculae residue post swallow

There was no evidence of aspiration and only trace penetration, which was cleared on the initial swallow, during the study.

The findings of this assessment are consistent with generalized progressive muscle weakness secondary to Muscular Dystrophy.

RECOMMENDATIONS:

• Thin fluids
• Soft moist diet – to help keep the bolus more cohesive and to reduce valleculae residue.

      e.g. having extra gravy/sauce with your food.

• Small mouthfuls/sips
• Allow time for multiple clearing swallows to clear residue before taking another mouthful/sip

Reflection

·      ANATOMY: The adult larynx is located around the level of C3-6, the hyoid can be seen on the VF and is a marker, as is the epiglottis.

·      Focusing on a) Oral Phase b)Transfer and c) Pharyngeal phase was useful rather than everything as a whole.

·      Looking for aspiration down the airway anterior to the oesophagus was useful.