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. Author manuscript; available in PMC: 2015 Feb 18.
Published in final edited form as: J Med Speech Lang Pathol. 2013 Sep;21(3):3.

Severe Idiopathic Dysphagia in an Acute Hospital Setting: Assessment, Management, and Outcome

Inga Simning 1,2, Adam Simning 3
PMCID: PMC4332583  NIHMSID: NIHMS626367  PMID: 25705102

Abstract

This case describes the course of a patient who was admitted to an acute care hospital with pneumonia and odynophagia and found to have severe, idiopathic oropharyngeal dysphagia. The assessment, treatment, and outcome are reported alongside suggestions for best practice in the treatment of dysphagia in hospital settings. Timely instrumental assessment, interdisciplinary management, and post-discharge follow-up were needed to provide optimum care and to achieve a positive outcome for this patient with life-threatening dysphagia.

BACKGROUND

Dysphagia has been defined as difficulty moving food from the mouth to the stomach (Logemann, 1998). Well-established risk factors for dysphagia include advanced age, neurological disease, head-neck cancer, and pulmonary disease (Garon, Sierzant, & Ormiston, 2009; Smith, Logemann, Colangelo, Rademaker, & Pauloski, 1999). Dysphagia with concurrent altered mental status places adults at especially high risk for foreign body aspiration (Leder, Suiter, & Lisitano Warner, 2009; Paintal & Kuschner, 2007). It follows that foreign body aspiration may be more common in an acute hospital setting because patients often have multiple medical comorbidities that put them at risk for dysphagia in addition to frequently having an altered mental status (Bucht, Gustafson, & Sandberg, 1999). Most patients who aspirate, however, do so silently (Smith, Logemann, Colangelo, Rademaker, & Pauloski, 1999; Leder, Sasaki, & Burrell, 1998; Garon, Engle, & Ormiston, 1996), often resulting in aspiration that is undetected and untreated. Undetected aspiration is a serious clinical concern as it can lead to insidious lung damage, aspiration pneumonia, or asphyxiation. Aspiration pneumonia is associated with increased length of hospital stay, cost, in-hospital mortality, and risk for admission to the ICU (Kozlow, Berenholtz, Garrett, Dorman, & Pronovost, 2003), making appropriate management of the dysphagic patient critical.

In an acute care hospital, the optimal management of dysphagia requires that the speech-language pathologist (SLP) work with a multidisciplinary team (Duval, Black, Gesser, Krug, & Ayotte, 2009; Heritage, 2001). This team can include internists, neurologists, pulmonologists, radiologists, gastroenterologists, otorhinolaryngologists, occupational therapists, respiratory therapists, dieticians, and nurses. In a standard swallowing consult, the SLP assesses the patient using a bedside dysphagia assessment and, if indicated, an instrumental study. The most commonly used instrumental studies are the fiberoptic endoscopic examination of swallowing (FEES) and the modified barium swallow (MBS) (Leder, Sasaki, & Burrell, 1998; Garon, Sierzant, & Ormiston, 2009), both of which are now considered to be the gold standard in dysphagia assessment (Rao, Brady, Chaudhuri, Donzelli & Wesling, 2003). Based on the evaluation results, the SLP makes recommendations for safe diet consistencies, swallowing strategies, and dysphagia therapy if indicated. Considerable variation exists in the clinical practice of SLPs regarding the indications for an instrumental evaluation, the determination of which patients are suitable for therapy, and the formulation of a therapy plan that is appropriate in the acute setting (Mathers-Schmidt & Kurlinski, 2003; Pettigrew & O’Toole, 2007). Unfortunately, when patients are discharged from the hospital, diet recommendations and follow-up instructions are lacking in the discharge paperwork of nearly half of patients going to sub-acute care (Kind, Anderson, Hind, Robbins, & Smith, 2011), leaving patients at risk for recurrent aspiration.

The aim of this case study is to share the story of the assessment, management, and outcome of a patient with an unusual case of severe dysphagia in an acute care hospital. This case study highlights several important points for the SLP treating dysphagia in medical settings: 1) the need for timely instrumental assessment of patients with dysphagia, 2) the necessity for aggressive dysphagia therapy in the acute care setting with regular instrumental assessment to inform treatment, 3) the importance and nuances of interdisciplinary management of the dysphagic patient, and 4) the SLP’s responsibility in promoting appropriate dysphagia follow-up.

METHODS

Subject

The subject of this case report is a 61 year old female, FB, who has a past medical history notable for stroke, diabetes mellitus type II, chronic renal failure requiring dialysis, chronic obstructive pulmonary disease, and gastroesophageal reflux disease. FB was admitted to a tertiary medical center with complaints of one week duration of headache, shortness of breath, odynophagia, and dysphagia. Additionally, her medical history includes personality disorder, anxiety, depression, obesity, asthma, obstructive sleep apnea, and tobacco abuse. FB was on 20 medications to manage her illnesses including Risperidone, an antipsychotic that has been reported in the literature to cause dysphagia (Sokoloff & Pavlakovic, 1997). FB was a medically complex patient with many risk factors for dysphagia.

A neck CT taken on the day of admission revealed a 1.8 cm by 1.2 cm soft tissue mass in the left supraglottic region. Direct laryngoscopy and biopsy by an ear-nose-throat specialist (ENT) revealed a benign mass extending from the left aryepiglottic fold into the left pyriform sinus along with a left vocal fold paralysis. No direct intervention was recommended at the time.

Three days into her hospital stay, FB experienced cardiac arrest while eating a danish. During resuscitation, a food bolus was removed from her pharynx. Following patient stabilization, speech pathology was consulted to evaluate the patient for dysphagia. FB remained in the hospital for a total of 62 days; she was followed by speech pathology from hospital day 11 until the day of her discharge.

RESULTS

Initial Bedside Evaluation and MBS – Hospital Day 11 and 14

The initial bedside swallow evaluation completed by an SLP was significant for a severely hoarse and hypophonic voice, a right-deviated velum, decreased labial and lingual range of motion, a lingual tremor, multiple swallows, and a weak congested baseline cough that continued throughout per os (PO) trials of regular liquid, nectar thickened liquid, and puree.

A MBS was completed to further evaluate FB’s oropharyngeal swallow. The MBS revealed severe oropharyngeal dysphagia with poor anterior-to-posterior bolus propulsion, severely delayed swallow onset, no epiglottic inversion, and minimal hyolaryngeal elevation. Multiple attempts to swallow one teaspoon of puree resulted in gross, silent aspiration of approximately 30% of the bolus, severe pharyngeal residue, and none of the bolus passing through the upper esophageal sphincter (see Figure 1). The pureed consistency was chosen for the first trial because studies have shown thicker consistencies are less likely to be aspirated than thinner consistencies (Diniz, Vanin & Parente, 2009). Based on the extremely delayed swallow onset and lack of laryngeal closure it was presumed that a thinner consistency would not reduce aspiration risk. Due to the patient’s compromised respiratory status, inability to produce a productive cough, and high risk of aspiration with further trials, the MBS was discontinued after administration of 1 teaspoon of puree.

Figure 1.

Figure 1

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MBS on hospital day 14 showing (a) a puree bolus swallow with penetration during the swallow and (b) subsequent aspiration of about 30% of the bolus.

Treatment – Hospital Days 15 to 26

FB had many risk factors that are known to be associated with dysphagia including a history of stroke (9 years prior with no residuals), pulmonary illness, the use of a neuroleptic drug (she had been on Risperidone for 6 months), and a pharyngeal mass. However, none of these could fully account for the severity and onset of her dysphagia which involved severely impaired oral and pharyngeal phases with absent sub-glottic sensation. Thus, in addition to providing safe nutrition, a major aspect of FB’s care included determining an etiology and treatment for her dysphagia. Following the SLP evaluation, recommendations were made for: non-oral nutrition with aggressive dysphagia therapy, ENT follow-up for vocal fold paralysis and pharyngeal mass, and neurology assessment to assist in determining the etiology of the dysphagia to help guide appropriate treatment. The medical team recommended long-term non- oral nutrition via percutaneous endoscopic gastrostomy (PEG) placement, which was declined by the patient and her family. Instead, FB continued strict nil per os (NPO) status with non-oral nutrition via Dobhoff tube.

Re-evaluation by ENT revealed continued left vocal fold paralysis, but that the pharyngeal mass seen during previous endoscopy had spontaneously resolved and likely represented pharyngeal edema rather than a true mass. The ENT physician was unable to determine a cause of FB’s dysphagia as there was no gross anatomical change to the larynx or pharynx. He hypothesized that the dysphagia may have been related to a stroke. The neurologist, however, had low clinical suspicion of a stroke, and he conjectured that FB’s dysphagia was due to nerve dysfunction from the mass compressing the nerve plexus or from damage to the laryngeal nerves from chronic cigarette smoke.

Without a confirmed etiology for FB’s dysphagia to guide medical or surgical treatment, the team agreed that aggressive swallowing therapy was the most appropriate approach. FB participated in dysphagia therapy with an SLP three to five times a week and also independently performed swallowing exercises in-between therapy sessions. The evidence-based swallowing exercises concentrated on improving tongue base retraction and laryngeal rise (Burkhead, Sapienza, & Rosenbeck, 2007; Logemann, 2008). FB consistently participated well in therapy and was motivated to complete her swallowing exercises independently. No oral trials were used during these first two weeks due to her high risk for aspiration.

2nd MBS – Hospital Day 27

On Hospital Day 27, a second MBS was completed to assess for improvement in swallowing and to assist in determining a more permanent feeding plan. FB continued to have poor mastication, impaired bolus transit, reduced hyolaryngeal excursion, and pharyngeal weakness with moderate-to-severe diffuse pharyngeal residue. Her swallow initiation and airway protection had improved substantially from the first MBS. FB’s swallow was consistently triggered at the base of her tongue or at her vallecula, her laryngeal rise had improved, and her epiglottis inverted fully to cover her airway. She demonstrated no aspiration of any consistencies, and only trace penetration with thin liquids. Two additional swallows followed by a nectar thick liquid wash were effective in reducing pharyngeal residue (see Figure 2).

Figure 2.

Figure 2

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MBS on hospital day 27 showing (a) a puree bolus swallow with no penetration during the swallow and (b) diffuse residue after the swallow.

Treatment – Hospital Days 28 to 56

Based on the results of the second MBS, FB initiated a pureed diet with nectar thick liquids. She had full supervision with meals, used two swallows for every bite, and alternated solids and liquids. Her diet tolerance was monitored closely by an SLP. Her diet was discontinued after three days because she demonstrated overt signs of aspiration during meals (throat clearing, intermittent coughing, and a wet vocal quality) and her lung sounds became diminished. At that time, the decision was made to pursue PEG placement to allow FB to be considered for discharge to a nursing home while she continued to rehabilitate her swallow.

An ENT re-evaluated FB using endoscopy and found continued left vocal fold paralysis and pooling of secretions, but no lesions or masses. He also noted a resting tremor in FB’s hands and tongue. He reiterated that the vocal fold paralysis did not appear to be from a neoplastic etiology, but rather was likely a neurological process. A neurologist was therefore asked to re-evaluate FB. The neurologist reported that recurrent laryngeal nerve damage was possible, but a primary neurologic disorder was unlikely in the absence of other neurological findings.

After PEG placement, FB continued to have intensive dysphagia therapy. Goals and exercise methods were modified to target her current swallowing deficits, primarily those of pharyngeal weakness and reduced hyolaryngeal excursion. To target these specific areas, neuromuscular electrical stimulation (VitalStim®) was used in the 3a position in conjunction with swallowing exercises including Mendelsohn swallow, Masako tongue hold, pitch glides, tongue retraction, and effortful swallow to facilitate muscle recruitment (Wijting & Freed, 2007). PO trials with purees and honey thick liquids were included in therapy. FB used five effortful swallows per bolus. By week five, FB was showing improved tolerance of PO trials with no coughing, no changes in vocal quality, and only occasional throat clearing.

3rd MBS -- Hospital Day 57

A third MBS was completed on hospital day 57 to determine if FB’s swallow had improved sufficiently to support re-instatement of an oral diet. The MBS was completed in both lateral and anterior-posterior views, and revealed mild oral and moderate pharyngeal dysphagia. Pharyngeal strength was notably improved from the previous study with only mild-to-moderate pharyngeal residue that was greater in the left pyriform sinus than the right (see Figure 3). Airway penetration occurred with nectar thick liquids and regular liquids with a throat clear response. A head turn to the left, multiple swallows, and alternating liquids and solids were effective strategies to improve FB’s pharyngeal residue clearance.

Figure 3.

Figure 3

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MBS on hospital day 57 showing (a) a puree bolus swallow with no penetration during the swallow and (b) mild vallecular and pyriform residue after the swallow.

Treatment – Hospital Days 58 to 61

Based on the improvement seen in the third MBS, FB was able to initiate a pureed diet with honey thick liquids. Therapy focused on reinforcing swallowing strategies, monitoring tolerance, and continuation of swallowing exercises. By the end of the week, FB independently used swallowing strategies consistently, met her nutritional needs by mouth, and demonstrated good diet tolerance with no pulmonary compromise. At this time she was discharged from the hospital to a skilled nursing facility with recommendations for continued dysphagia therapy. The SLP communicated with social work the need for ongoing dysphagia therapy, called the nursing facility to report FB’s recommended diet, and faxed the MBS reports, therapy notes, and therapy plan to the nursing home SLP.

Follow-Up – Post-Hospital Day 22

Following hospital discharge, FB received three weeks of dysphagia therapy in short- term rehabilitation at a nursing home. Prior to discharge home, FB returned to the hospital for a FEES in order to monitor her progress and assess for diet upgrade. FB independently executed swallowing strategies learned over two months ago, had maintained the recommended diet, and had not experienced any pulmonary complications during this time. The FEES revealed stable swallowing function, which supported upgrading the diet to soft solids and nectar thick liquids with continuation of the same swallowing strategies. Continued dysphagia therapy with a home care service was recommended for diet teaching and tolerance monitoring. Results were sent to FB’s primary care provider.

DISCUSSION

This case highlights several important points regarding the assessment, management, and follow-up of patients with dysphagia in medical settings.

As stated previously, SLP assessment and treatment of dysphagia in the acute hospital setting vary widely (Mathers-Schmidt & Kurlinski, 2003; Pettigrew & O’Toole, 2007). SLP’s have many available tools when it comes to swallowing assessment, including both bedside and instrumental techniques. Unfortunately, even the most detailed bedside protocols completed by experienced clinicians continue to have significant shortcomings. Studies have found that over half of patients who aspirate do so silently (i.e., without a cough reflex) making it difficult to identify aspiration at the bedside (Garon, Engle, & Ormiston, 1996; Smith, Logemann, Colangelo, Rademaker & Pauloski, 1999). Careful bedside examinations have been found to have sensitivities ranging from 86% to 100% and specificities from 29% to 78% when compared to instrumental studies (Clave et.al., 2008; Leder & Espinosa 2002; Lim et. al., 2001; Perry & Love, 2001). Furthermore, because pharyngeal structures are not viewed, the bedside swallow evaluation cannot be used to determine the physiologic or anatomical cause of aspiration, thereby making it difficult to plan targeted treatment. Some SLPs prefer to defer instrumental assessment for patients who show no overt signs of aspiration at bedside (e.g., coughing or choking with food trials) and instead trial a modified diet and monitor that patient’s tolerance (e.g., oral intake, pulmonary status, patient complaints). Such an approach may have considerable risks for the patient who is medically fragile or has a compromised respiratory status. In this case, prompt instrumental evaluation was warranted because of the patient’s recent history of pneumonia, choking, and asphyxiation, as well as the known anatomical changes from the pharyngeal mass that impact swallowing and need to determine if and what type of therapy was appropriate. Both MBS and FEES were considered, but MBS was ultimately chosen because the therapists suspected the pharyngeal mass may impair visualization of the glottis and any possible aspiration during a FEES.

A wide range of therapy techniques is available to the SLP; however, research on the effectiveness of these techniques is unfortunately limited (Ashford et. al., 2009). Consequently, most SLPs use a combination of compensatory and restorative therapies to treat dysphagia. Compensatory therapies aim to improve the efficiency and safety of the swallow without changing its physiology, thereby “compensating” for the swallowing deficit. Compensatory strategies include postural changes, swallowing maneuvers, altering sensory input, and changing PO consistency. Postural changes have shown to reduce aspiration of liquid consistencies in 77% of cases (Rasley et. al., 1993). Thickening the consistency of liquids reduces aspiration risk by 50%-87% depending on the viscosity used (Fink & Ross, 2009; Diniz, Vanin, & Parente, 2009).

Restorative therapies aim to strengthen the oral and pharyngeal muscles and improve the timing and coordination of the swallow response. These therapies include traditional oral-motor exercises and neuromuscular electrical stimulation (NMES). There is only limited support for both of these techniques in the literature (Ashford et. al., 2009; Huckabee & Deoltegen, 2007). Another technique, tactile-thermal stimulation, has been shown to improve swallow onset timing for several swallows after stimulation of the faucial pillars with a cold laryngeal mirror (Lazzara, Lazarus, & Logemann, 1986).

SLPs may be hesitant to treat dysphagia unless they know the etiology. In the case presented here, however, an empiric trial of dysphagia treatment provided considerable benefit to the patient. FB’s dysphagia was idiopathic and could not be fully explained by any known recent neurological events, changes in mental status, medication changes, or surgical procedures. Her dysphagia, however, was severe and involved silent aspiration. FB’s dysphagia treatment was rigorous (often an hour a day), individualized to target her swallowing physiology as evidenced on the MBS, and regularly modified to match her improving swallow. Her therapy plan included both compensatory strategies (e.g., modified consistencies, multiple swallows, and posture changes) and restorative therapies (e.g., tongue-base exercises and NMES). Consistent SLP involvement throughout her hospitalization played an important role in FB’s medical management and positive outcome. Given the severity of her dysphagia, had FB prematurely reinstated an oral diet, she would have been at high risk of developing a recurrent aspiration pneumonia or possibly even death by asphyxiation (as had almost occurred prior to SLP involvement). In this case, SLP involvement including multiple instrumental assessments, teaching of swallowing strategies, and careful patient monitoring were necessary at the acute-care level for safe diet reinstatement.

Interdisciplinary management of dysphagia in the hospital is necessary for establishing an etiology, providing targeted treatment, sustaining adherence to the treatment plan, ensuring patient safety, maintaining adequate nutrition, and maintaining proper follow-up. The SLP should play an active role in referral to other specialties and communication with the medical team. Many patients who have complaints of swallowing difficulty have had neurological damage or an undiagnosed neurological disease (Buchholz, 1994). This accentuates the importance of referring such patients to a neurologist for further diagnostic assessment and treatment. FB’s treatment team included an internist, a psychiatrist, an otorhynolaryngologist, a neurologist, clinical ethics, speech-language pathologists, radiologists, a gastroenterologist, a dietician, a social worker, and nurses. In this case, limited communication between the SLP, ENT, and neurologist may have contributed to the perfunctory neurological assessment, the contradictory conclusions between ENT and neurology, and the inability to establish an etiology for FB’s dysphagia. While social workers organize discharge and follow-up services for patients, a conscientious SLP can ensure that appropriate diet and SLP services are initiated at the discharge location with a quick phone call. Even after FB’s hospital discharge, the acute care SLP’s involvement continued through communication with the next SLP and additional instrumental re-assessment upon the completion of a month of post-discharge therapy. This type of SLP-initiated inter-facility communication is optimal as dysphagia recommendations are likely to be missing from hospital discharge instructions (Kind, Anderson, Hind, Robbins, & Smith, 2011) which can pose a great risk to patients with silent aspiration. Additionally, the patient played an important role in her own medical management by performing dysphagia exercises independently and making an informed decision on when she was ready for a PEG.

In an acute medical setting where resources are limited, caseloads are high, and hospital policies often dictate treatment options, ideal dysphagia assessment and treatment cannot be accomplished for every patient. Despite these challenges, SLPs should embrace their important role as a communicator within the interdisciplinary medical team. In many cases, something as simple as making a referral or follow-up phone call can significantly improve a patient’s clinical outcome (Cup et al., 2011).

AKNOWLEDGEMENTS

Adam Simning is a MD/PhD candidate in University of Rochester’s Medical Scientist Training Program funded by the National Institutes of Health (NIH) T32 GM007356 grant.

Footnotes

Conflict of Interest: No disclosures to report.

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