Medical history: 63 year-old male w/ respiratory failure, HLD, HTN, CAD, DM, protein calorie malnutrition, severe hepatitis C, acute CVA w/ L hemiplegia, colon CA, and s/p CABG. Pt had a Shiley #6 cuffless trach in place.

Current diet:  NPO/PEG

HINTS

Watch the video, then open the VIEW HINTS tab to see any available hints prior to viewing the results.

HINTS: 

Notice the long uvula.

Laryngeal penetration occurred at 1:22, 2:45, 3:45, 4:54, 7:50, and 9:50.

VIEW RESULTS 

Open the VIEW RESULTS tab below after making your own interpretation.

Summary: 

Patient-7-Summary

 

Pt was seen sitting up in chair w/ Passy Muir Valve in place. Primary SLP was present for exam. Endoscopic findings included:  1. arytenoids appeared fixed at midline with limited ROM, 2. incomplete TVC closure with phonatory tasks, coughing/throat clearing, 3. reduced ROM of B TVC (slight movement of R TVC), and 4.) hyperfunction of R ventricular vocal fold. Larynx appeared to shift to the R during the swallow due to significant L sided pharyngeal weakness. Pt demonstrated a severe pharyngeal dysphagia c/b: reduced hyolaryngeal elevation, laryngeal closure, epiglottic ROM; poor airway protection; reduced larygneal sensation; reduced pharyngeal strength on L, and suspected reduced/incomplete UES opening. Collectively, this contributed to: 1. silent laryngeal penetration to the level of the TVCs before and during the swallow with all consistencies; 2. trace, silent aspiration w/ thins; 3. residual at UES after the swallow with NTL, HTL, and pureed; and 4. laryngeal penetration after the swallow with NTL. Laryngeal sensation was likely reduced, as reflexive  coughing did not always follow penetration/aspiration. In addition, cued coughing was minimally effective in clearing penetrated/aspirated material. Frothy secretions were pooled at UES at baseline, clearing w/ po presentation.

Recommendations:
Diet:  NPO
1. Consider ENT consultation to address incomplete TV closure and determine possible solutions
2. Consider consulting Respiratory Therapy for possible decannulation, which may improve overall swallow function.
3. Ongoing ST to maximize swallow function, including trials w/ ice chips, thin liquids and other consistencies as tolerated.