1. Dysphagia following Anterior
Cervical Discectomy and Fusion
Danielle Clark B.S.
Case supervisor: Elizabeth Biggio MA CCC-SLP
Case Moderator: Dr. Lisa LaGorio
2. LEARNING OBJECTIVES
• Provide an overview of the Anterior Cervical
Discectomy and Fusion procedure
• Review the effects ACDF has on swallowing
• Review current literature on dysphagia in ACDF
patients
3. • Cervical Discectomy and Fusion (CDF):
surgery to remove a herniated or
degenerative disk of the cervical spine
• Surgery consists of two parts
• Discectomy: Cutting the disk
• Fusion: Insertion of a graft in the
empty disc space between two
vertebrae
Anterior Cervical Discectomy and Fusion
4. • Anterior Approach:
• Damaged disc accessed without
disturbing the spinal cord
• Incision made in throat area
• Neck muscles, trachea, and
esophagus moved to the side to
access spine
• Risk of dysphagia and dysphonia
• Posterior approach
• Incision made in the back of the
neck to access spine
• Risk of dysphonia, dysphagia,
tetraplegia 4
Anterior vs Posterior approach
5. Discectomy
• Single or Multi-level
• One disk is removed,
space between
vertebrae must be filled
Anterior Cervical Discectomy and Fusion
6. • Bone graft inserted to fill open
disk space
– Prevents collapse of
vertebrae
• Graft connects two vertebrae to
create spinal fusion
– Autograph: Bone removed
from patient’s hip used for
graft
• Bone graft fusion reinforced with
metal plate screwed into
vertebrae
Anterior Cervical Discectomy and Fusion
Fusion
8. Question for the audience
• What would you expect swallowing to look
like in an ACDF patient?
9. Dysphagia following ACDF
• Dysphagia is the one of the most common
complications following ACDF
• Swallowing Characteristics after ACDF
• Swelling of pharyngeal wall
• Reduced hyolaryngeal elevation
• Impaired epiglottic inversion
• Poor pharyngeal constriction
• Increased transit time
• Reduced UES opening
• Increased aspiration
10. • Clinical Signs
• Reflexive coughing
• Globus sensation
• Wet/gurgly voice after swallow
• Extra effort or time to chew or swallow
• Multiple swallows
• Recurring pneumonia
• Weight loss
• Dehydration
Dysphagia following ACDF
11. Anderson, K. K., & Arnold, P. M. (2013). Oropharyngeal dysphagia after anterior
cervical spine surgery: A review. Global Spine Journal, 3(4), 273-285.
• Purpose: Literature review on postoperative
dysphagia after anterior cervical spine surgery (ACSS)
• Bazaz Dysphagia Score most commonly used
assessment to assess dysphagia after ACSS
• Patients’ dysphagia symptoms graded based on
telephone interviews
12. Anderson, K. K., & Arnold, P. M. (2013). Oropharyngeal dysphagia after anterior
cervical spine surgery: A review. Global Spine Journal, 3(4), 273-285.
13. • Damage of aerodigestive
pathway
• Tissue damage with
edema
• SLN injury leading to
laryngeal sensory
impairment
• Injuries to the pharyngeal
plexus or vagus nerve,
glossopharyngeal nerve,
or hypoglossal nerve
• Prevertebreal soft tissue
swelling
• Posterior pharyngeal wall
edema
• Esophageal edema
• Esophageal denervation
• RLN injury
Anderson, K. K., & Arnold, P. M. (2013). Oropharyngeal dysphagia after anterior
cervical spine surgery: A review. Global Spine Journal, 3(4), 273-285.
Causes of dysphagia due to operative techniques
14. • Dysphagia is the most common postoperative patient complaint
after ACSS
• Incidence of dysphagia 1 week post ACSS: 1 to 79%
• Incidence in intermediate to long term postoperative period (1-6
weeks): 28-57%
• Risk factors for dysphagia
• Greater number of levels operated
• Female
• Increased operative time
• Older age (>60 years)
Anderson, K. K., & Arnold, P. M. (2013). Oropharyngeal dysphagia after anterior
cervical spine surgery: A review. Global Spine Journal, 3(4), 273-285.
15. • Purpose: Assess incidence of dysphagia and present the
changes of findings in VFSS after ACDF
• Participants: 47 ACDF patients diagnosed with radiculopathy
or myelopathy
• Patients evaluated for preoperative and postoperative
dysphagia, 1 week and 1 month post-surgery
• Dysphagia assessed using:
• BAZAZ Dysphagia Score (BDS)
• VFSS based penetration-aspiration scale
• Functional dysphagia scale (FDS)
Min, Y., Kim, W., Kang, S. S., Choi, J. M., Yeom, J. S., & Paik, N. (2016). Incidence of dysphagia and serial
videofluoroscopic swallow study findings after anterior cervical discectomy and fusion. Clinical Spine
Surgery, 29(4), E177-E181.
16. • Results:
• 1 Week follow-up
• 83% reported dysphagia (BDS)
• 4.3% had aspiration
• 1 month follow-up
• 59.6% reported dysphagia
• 4.3% had aspiration
• No significant changes in oral transit time, pharyngeal transit time, or
pharyngeal delay time
• Conclusions:
• Dysphagia is common until 1 month after ACDF
• High incidence of aspiration and penetration but no reported PNA
• Dysphagia characterized by post-swallow residue in the valleculae and
pyriform sinuses
Min, Y., Kim, W., Kang, S. S., Choi, J. M., Yeom, J. S., & Paik, N. (2016). Incidence of dysphagia and serial
videofluoroscopic swallow study findings after anterior cervical discectomy and fusion. Clinical Spine
Surgery, 29(4), E177-E181.
17. • Limitations
– No information on how transit times were
measured
– Use of FDS
• Penetration:
– Sensitivity 81%
– Specify: 70.7%
• Aspiration
– Sensitivity: 78.1%
– Specificity: 77.9%
Min, Y., Kim, W., Kang, S. S., Choi, J. M., Yeom, J. S., & Paik, N. (2016). Incidence of dysphagia and serial
videofluoroscopic swallow study findings after anterior cervical discectomy and fusion. Clinical Spine
Surgery, 29(4), E177-E181.
18. Patient A
• Caucasian female in her 50s
• Admitted to inpatient rehab following C4-C7 ACDF surgery
• Presented with worsening diffuse weakness and gait
dysfunction
• PMH:
• Cervical myelopathy
• Cervical radiculopathy
• Bilateral arm weakness
• Impaired gait
• Traumatic cervical fracture
• Possible MS
19. Clinical Swallow Evaluation Findings
• Oral phase:
– Reduced bolus formation and control
– Reduced mastication
– Increased oral transit time
• Pharyngeal phase
– Delayed response trigger 1-2 seconds
– Reduced hyolaryngeal elevation resulting in multiple swallows
for purees
• Puree required 2 swallows
– Throat clearing present with thin liquids
– Functional swallow with Nectar thick liquids through straw sips
22. VFSS findings
• Oral phase
• Reduced bolus formation and control
• Disorganized A-P transport
• Premature spillage
• mid-posterior tongue residue
• Pharyngeal phase
• Delayed trigger 1-2 seconds
• Poor airway protection due to reduced hyolaryngeal excursion
• Reduced epiglottic retroflexion
• Decreased pharyngeal constriction
• Poor BOT and PPW approximation
• Residue: BOT, valleculae, and posterior pharyngeal wall
• Penetration/Aspiration with thin liquids
23. VFSS Findings
• Recommendations for Patient A:
– Dysphagia Diet with NTL
– No mixed textures
– Continue with dietary restrictions
– Smaller, more frequent meals due to decreased endurance
• ENT Consult
• Mild dysphonia characterized by :
• mildly hoarse, breathy vocal quality
• reduced endurance for conversational exchange due to
poor breath support
24. Question for the audience
• What swallow findings were not consistent
with what is typically seen post ACDF?
25. Patient A
• Medical history indicated possible diagnosis of
multiple sclerosis
• Seen by neurologist prior to admission to
inpatient rehab but diagnosis not confirmed
26. Multiple Sclerosis
• Inflammatory, demyelinating, neurodegenerative disorder of
the central nervous system (CNS)
• Unknown etiology
• Peak onset: 20-40 years
• Women affected 2x as often as men
• Common symptoms
– Fatigue
– Weakness
– Sensory and/or motor dysfunction of the limbs
– Spasticity
– Gait dysfunction
– Vision loss
27. Characteristics of Dysphagia in MS
• Oral Stage:
• Difficulties with bolus control and formation
• Poor labial, lingual, and jaw strength
• Mastication difficulties
• Pharyngeal Stage
• Decreased hyolaryngeal elevation
• Decreased pharyngeal constriction
• Delayed swallow trigger
28. • Purpose: Conduct a systematic review to establish
the prevalence of dysphagia in multiple sclerosis
• 15 studies reviewed
• All studies enrolled patients from neurology or MS
center
• Studies split into subjective screening and objective
measurement groups
• Objective: clinical or instrumental exam to detect
dysphagia
• Subjective screening: questionnaire surveys
Guan, X., Wang, H., Huang, H., & Meng, L. (2015). Prevalence of dysphagia in multiple sclerosis: a
systematic review and meta-analysis. Neurological Sciences, 36(5), 671-681.
http://dx.doi.org/10.1007/s10072-015-2067-7
29. • Subjective screening
– 12 studies
– Dysphagia in Multiple Sclerosis Questionnaire
(DYMUS) most widely used
• Objective Screening
– 4 studies
– VFSS/FEES
Guan, X., Wang, H., Huang, H., & Meng, L. (2015). Prevalence of dysphagia in multiple sclerosis: a
systematic review and meta-analysis. Neurological Sciences, 36(5), 671-681.
http://dx.doi.org/10.1007/s10072-015-2067-7
30. Dysphagia in Multiple Sclerosis Questionnaire (DYMUS)
• 10 items
• Items scored 1 or 0 indicating the presence or absence of an
event
• Questions
– Difficulties swallowing food or liquid
– Globus sensation
– Coughing after liquid or solid ingestion
– Multiple swallows
– Weight loss
31. • Dysphagia prevalence rates:
– Objective group: 81%
– Subjective group: 36%
• Limitations:
• No unified diagnostic method to identify
dysphagia in MS
• Lack of cohort or case-control studies
• Study population only included Europeans from
developed countries
Guan, X., Wang, H., Huang, H., & Meng, L. (2015). Prevalence of dysphagia in multiple sclerosis: a
systematic review and meta-analysis. Neurological Sciences, 36(5), 671-681.
http://dx.doi.org/10.1007/s10072-015-2067-7
32. Patient A Plan of Care
• Dysphagia therapy 5x week
• Goals
• Safe tolerance of recommended diet (dysphagia diet
with NTL) with dysphagia precautions
• Dysphagia exercises x20 reps
• Effortful swallow
• Masako
• Falsetto
• Lingual press/resistance
36. Pre vs. Post-Therapy VFSS
Before Therapy After Therapy
Delayed 1-2 seconds Swallow Response Timely
Reduced Hyolaryngeal
excursion
Adequate
reduced Epiglottic retroflexion reduced
Reduced Pharyngeal
Constriction
Reduced
Reduced BOT/PPW
approximation
Reduced
Present Penetration Flash with thin liquids
Present Aspiration Absent
37. Post-Therapy VFSS results
• Improved, presenting with mild oropharyngeal dysphagia
• Diet recommendation
• Mechanical soft
• Thin liquids with swallowing strategies
• Safe swallowing strategies
• small bites/sips
• multiple swallows per bolus
• x2 with liquids and x3 with solids
• tilt head forward/down with solids
• cough/clear throat
38. Patient A Update
• Late summer 2016
– discharged from rehab
– Diagnosed with vocal fold paralysis and muscle
tension dysphonia
– Received vocal fold injection to medialize
paralyzed VF after discharge
• Fall 2016
– Upgraded to general diet with thin liquids
– Multiple Sclerosis diagnosis confirmed
– Re-admitted to inpatient rehab
39. Take Home Points
• Dysphagia is a common complication following ACDF
• Dysphagia is common in patients with multiple
sclerosis
• It is important to consider that the majority of
patients will not have a straightforward case
• Patients are complex, and often times the presenting
diagnosis may not be the complete diagnosis
40. • Anderson, K. K., & Arnold, P. M. (2013). Oropharyngeal dysphagia after anterior cervical spine surgery: A
review. Global Spine Journal, 3(4), 273-285.
• Anterior Cervical Discectomy & Fusion (ACDF). (2016). Retrieved from http://www.mayfieldclinic.com/PE-
ACDF.htm
• Bergamaschi, R., Crivelli, P., Rezzani, C., Patti, F., Solaro, C., Rossi, P., ... Cosi, V. (2008). The DYMUS
questionnaire for the assessment ofdysphagia in multiple sclerosis. Journal of the Neurological Sciences,
269, 49-53. http://dx.doi.org/10.1016/j.jns.2007.12.021
• De Pauw, A., Dejaeger, E., D’hooghe, B., & Carton, H. (2002). Dysphagia in multiple sclerosis. Clinical
Neurology and Neurosurgery, 104(4), 345-351.
• Fountas, K. N., Kapsalaki, E. Z., Nikolakakos, L. G., Smisson, H. F., Johnston, K. W., Girgorian, A. A., ...
Robinson, J. S. (2007). Anterior cervical discectomy and fusion associated complications. Spine, 32(21),
2310-2317.
• Guan, X., Wang, H., Huang, H., & Meng, L. (2015). Prevalence of dysphagia in multiple sclerosis: a
systematic review and meta-analysis. Neurological Sciences, 36(5), 671-681.
http://dx.doi.org/10.1007/s10072-015-2067-7
• Min, Y., Kim, W., Kang, S. S., Choi, J. M., Yeom, J. S., & Paik, N. (2016). Incidence of dysphagia and serial
videofluoroscopic swallow study findings after anterior cervical discectomy and fusion. Clinical Spine
Surgery, 29(4), E177-E181.
• National Multiple Sclerosis Society. (n.d.). MS Symptoms. Retrieved from
http://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms
• Northwestern Medicine. (2016). Anterior Cervical Discectomy and Fusion. Retrieved from
https://www.nm.org/conditions-and-care-areas/treatments/anterior-cervical-disectomy-and-fusion
• Paik, N. J., Kim, I. S., Kim, J. H., Oh, B. M., & Han, T. R. (2005). Clinical validity of the functional dysphagia
scale based on videofluoroscopic swallowing study. Journal of Korean Academy of Rehabilitation Medicine,
29(1), 43-49.
References
Editor's Notes
Hello everyone my name is Dani Clark and today I will be discussing dysphagia following Anterior Cervical Discectomy and Fusion. I would like to thank my case supervisor Elizabeth Biggio and case moderator Dr. Lisa LaGorio, for their aid in the creation of this presentation.
My learning objectives for today are to…
Which I will refer to as ACDF
Anterior cervical discectomy is a surgery to remove a herniated or degenerative disk in the cervical spine…you can the cervical spine labeled in the picture above.
The surgery consists of two different parts;
-Discectomy means “cutting the disk” and can be performed anywhere along the spine
-and Fusion, which is the insertion of a graft in the empty disc space between two vertebrae
I will discuss these more in depth momentarily
The A in ACDF refers to an anterior approach to surgery. I would like to compare an anterior vs a posterior approach.
With an anterior approach, The surgeon reaches the damaged disc from the front (anterior) of the spine through the throat area
-After an incision is made on the front of the neck
-the neck muscles, trachea, and esophagus are moved to the side to access the spine, allowing the disc and bony vertebrae to be exposed
-with this approach, there are risks of dysphagia and dysphonia
With a posterior approach: the spine is accessed posteriorly through the back of the neck
-There is still a risk of dysphonia and dysphagia—but there is an added risk of tetraplegia that is not seen with the anterior approach
-Because of the added risk of tetraplegia, an anterior approach is often preferred for patients who require cervical spine surgery
As I discussed earlier, discectomy is the cutting of the disc
A discectomy may be done for one level, or for more than one level of the cervical spine
The damaged Damaged disk is removed which leaves a space between the vertebrae that must be filled, usually with a bone graft.
The fusion portion of the surgery involves inserting a graft in the empty disc space between two vertebrae
-After the disc is removed, the space between the bony vertebrae is empty and prevent the vertebrae from collapsing and rubbing together, a bone graft is inserted to fill the open disc space
-The graft serves as a bridge between the two vertebrae to create what’s called a spinal fusion.
-For ACDF an Autograft is the gold standard –This is where bone is removed from the patient’s own hip and used for the graft
-The Bone graft fusion is often reinforced with a metal plate screwed into vertebrae, which you can see in the picture above. After the bone graft is completed and the hardware is in place--New cells will grow over the graft as the bone heals
There are several surgical complications that can result from ACDF…these are a few of the most common one
From most common complication to least
hematoma is an abnormal collection of blood outside of a blood vessel. It occurs because the wall of a blood vessel wall, artery, vein, or capillary, has been damaged and blood has leaked into tissues where it does not belong.
Myelopathy: disease/neurologic deficit of the spinal cord
RLN palsy—VF paralysis
Postoperative dysphagia is one of the most common complication following ACDF
Swallowing deficits commonly seen after ACDF include..
The authors of this article discussed ACSS, but not just specifically the discectomy and fusion I just discussed…ACSS (or any surgery that used an anterior approach to the cervical spine) can be used to treat numerous cervical disorders, including degenerative, traumatic, oncologic, inflammatory, congenital, vascular, or infectious conditions. This includes ACDF
The BAZAZ dysphagia score or the BDS…
The BDS rates severity of dysphagia as none, mild, mod or severe
Mild: no difficulty with liquids and only rare difficulty with solids
Moderate: no (or rare) difficulty with liquids and occasional difficulty with specific solids such as bread or steak
Severe: no (or rare) difficulty with liquids and frequent difficulty with most solids
Based on telephone interviews, the patients’ dysphagia symptoms were graded as mild, moderate, severe, or none
Issues with the BDS
(1) it is clinician-administered, which may introduce a bias by the therapist who interprets the patient’s condition
(2) it is oversimplified, which may result in a lack of discrepancy between patients
(3) it scores difficulties in swallowing solids worse than difficulties in swallowing liquids (when patients often experience the opposite)
-For example
(4) it has never been formally validated despite being widely used
RLN injury: can lead to diminished closure of glottis, denervation of the inferior pharyngeal constrictor and cricopharyngeus muscles
Laryngeal sensory impairment can lead to issues with the laryngeal cough reflex—risking aspiration pneumonia
The authors concluded that dysphagia…
The incidence of dysphagia 1 week after surgery ranged from from 1 to 79%
The Incidence in intermediate to long term postoperative period (Between 1-6 weeks): 28-57%
This brings me to my next piece of evidence, which is a very recent study by Min et al.
Radiculopathy refers to a set of conditions in which one or more nerves are affected and do not work properly (a neuropathy). This can result in pain, weakness, numbness, or difficulty controlling specific muscles.
Myelopathy: describes any neurologic deficit related to the spinal cord
BDS: rates dysphagia as none-severe in response to swallowing liquids and solids
47 participants—mean age of 55
Pen/Asp: 8 point scale to describe penetration and aspiration events (1—material does not enter airway, 8—material enters airway, passes below VFs and no effort is made to eject)
FDS: an objective scale directly converted from the physiological parameters of a VFSS (patients are given scores in different domains out of a total score of 100—the lower the score, the more severe the dysphagia)
Han TR, Paik NJ, Park JW. Quantifying swallowing function after
stroke: a functional dysphagia scale based on videofluoroscopic
studies. Arch Phys Med Rehabil. 2001;82:677–682.
Although rate incidence of asp was high, no pt presented with PNA (because neurological swallow mech is in tact)
Residue may be a result of soft tissue edema and poor pharyngeal constriction after ACDF (they graded residue 1,2,3)
This is not included in the slide but penetration decreased from 36% to 35% 1 week to 1 month post surgery
Study design: prospective study--prospective cohort study is a longitudinal cohort study that follows over time a group of similar individuals (cohorts) who differ with respect to certain factors under study, to determine how these factors affect rates of a certain outcome
Limitations: did not clearly discuss all methods: “The oral transit time (OTT), PTT, and pharyngeal delay time (PDT) were measured by the methods described elsewhere”—used temporal parameters of the functional dysphagia scale (contradicts other other findings that temporal parameters DO change after ACDF)
Weakness: Validated only on stroke patients
Strength: “is a sensitive and specific method for quantifying the severity of dysphagia”--The scale's sensitivity and specificity for detecting penetration and aspiration were 81%, 70.7%, and 78.1%, 77.9%, respectively
Sensitivity: true positive (correctly identifying the pen/asp present)
Specificity: true negative (correctly confirms person pen/asp is not present)
~This means that about 20% of the time the FDS is missing the identification of penetration and aspiration
Now I would like to introduce pt A.
Pt A is a….
Cervical myelopathy: Compression of the spinal cord in the neck—leads to pain and weakness in neck or arms
Cervical radiculopathy: clinical description of pain and neurological symptoms resulting from any type of condition that irritates a nerve in the cervical spine (neck).
Pt received clinical swallow eval approx 4 days post ACDF surgery
Assessment summary: Patient presents with minimal oral dysphagia with suspected pharyngeal dysfunction that appears most significantly impacted by recent ACDF procedure. Suspect pharyngeal swelling with concomitant generalized deconditioning, leading to decreased bolus control, weak pharyngeal mechanics and inefficient airway protection. Signs and symptoms of aspiration were evident with trials of thin liquids, and s/s of pharyngeal residue were noted w/ ALL tested consistencies. Suspect good laryngeal sensation. Patient is further limited by fear/anxiety related to eating and drinking due to her reported difficulty with swallowing. The safest and most efficient diet to maintain nutrition at this point is a pureed diet with nectar thick liquids. Recommend further objective testing via VFSS.
Talk about how BAZAZ and how it supports/doesn’t support
Can talk about MASA (this is being implemented at Rush)
Mild oral dysphagia and moderate pharyngeal dysphagia
- Patient to be seen for dysphagia therapy 3x/ week targeting the following goals:
LTG: Patient will demonstrate safe tolerance of the least restrictive diet.
STG:
- Patient will participate in (re)evaluation via BSSE/VFSS with additional recommendations to follow at acute rehab, if needed
- Patient will demonstrate safe tolerance of recommended diet with min A for dysphagia precautions x2 meal/snacks.
Patient will demonstrate tolerance of trials of thin without s/s aspiration or oral residue given min A for use of strategies for potential diet upgrade
Level 1: Pureed food
Level 2: Dysphagia
Level 3: Mechanical Soft
Level 4: General
PT A participated in a VFSS 4 days after the clinical swallow eval (so this is just over a week after surgery)
Thin liquids (1 teaspoon)
Tongue residue due to poor tongue strength
Trial Interventions and Results:
Aspiration: present with thins before during and after swallow
Chin Tuck. Results: effective w/ NTL to improve airway protection and vallecular clearance; not effective with thins
Cued Cough. Results: NOT effective even slightly; tracheal aspirant remains throughout almost entire study due to inability to clear
Repeat Swallows. Results: minimally effective with reducing amount of vallecular residue, needs 4-5 swallows per solid bolus
Breath Hold Before Swallow. Results: NOT effective, penetration and occasional aspiration persists
Supraglottic Swallow. Results: NOT effective, cough/throat clear is too weak
Effortful Swallow. Results: no significant difference with cues for "effortful" swallow vs additional swallow
From notes: no mixed textures (puree all fruits)
Dietary restrictions: paleo/ketogenic diet
Required strategies:
- NTL by TEASPOON to dec pen/asp and facilitate vallecular clearance
- CHIN TUCK all consistencies
- cough, re-swallow after initial bolus swallow
- swallow x3 or more per bolus
- alternate consistencies
Abnormal oral phase
Oral phase
Reduced bolus formation and control
Disorganized A-P transport
Premature spillage
mid-posterior tongue residue
As of summer 2016—patient had not been formally diagnosed with MS (patient was seen by neurology prior to admission to evaluate a dx of MS but it had still not been confirmed before her admission to JRB)
Update early Fall 2016—dx of MS changed from “possible dx” to actual dx
Gait abnormality is a deviation from normal walking (gait). Normal gait requires that many systems, including strength, sensation and coordination, function in an integrated fashion.
Presented with worsening diffuse weakness and gait dysfunction
The characteristics of dysphagia in MS for the pharyngeal stage overlap with those seen post ACDF
Objective group in included 4 studies
Subjective group included 12
A systematic review answers a defined research question by collecting and summarizing all empirical evidence that fits pre-specified eligibility criteria. A meta-analysis is the use of statistical methods to summaries the results of these studies.
**Ask which table to include….**
Study results show that dysphagia is identified more often using objective message (imaging) vs. subjective (questionnaire). Clinically, this is important because this reveals that patients with MS are not reporting dysphagia symptoms, when instrumental exams show that they do have dysphagia.
Ideally, Pt A would’ve had a swallowing eval as soon as she had a possible MS diagnosis.
Developed because there was no specific questionnaire for individuals with MS
Administered to 226 individuals with MS
A higher score indicates more severe dysphagia
Questions: Do you have difficulties swallowing solid food (such as
meat. bread. and the like)?
Do you have difficulties swallowing liquid (such as water,
milk, and the like)?
Do you have a globus sensation in your throat during
swallowing?
Do you have food sticking in your throat?
Do you cough or do you have a choking sensation after solid
ingestion?
Do you cough or do you have a choking sensation after
liquid ingestion?
Do you need to swallow more and more times before
completely swallowing solid food?
Do you need to cut food in small pieces before swallowing?
Do you need to take more and more sips before completely
swallowing liquid?
Do you have weight loss?
Cronbach's alpha is a measure of internal consistency, that is, how closely related a set of items are as a group. It is considered to be a measure of scale reliability.
Author’s state: DYMUS needs a further evaluation study
Suggests that at least 1/3 of MS patients suffer from dysphagia
As you can see, the prevalence in the subjective groups was much lower than the prevalence in the objective groups, meaning that instrumental exams identified dysphagia at a higher rate than patients who were reporting dysphagia via questionnaire.
Lack of cohort or case-control studies “hampered” inferences of causality (studies reviewed were mostly cross-sectional designs)
According to the authors: our included study population mainly came from Europe, all from developed countries, indicating that the representation of sample was not enough. Therefore, we should consider universal investigation of dysphagia around the world. In view of above-mentioned limitations, we should be cautious to estimate overall prevalence
Cohort or cross-sectional studies would have a higher level of evidence than a cross-sectional study
All studies were cross sectional: type of observational study that analyses data collected from a population, or a representative subset, at a specific point in time
Cohort study: A study design where one or more samples (called cohorts) are followed prospectively and subsequent status evaluations with respect to a disease or outcome are conducted to determine which initial participants exposure characteristics (risk factors) are associated with it. As the study is conducted, outcome from participants in each cohort is measured and relationships with specific characteristics determined
Case control: A study that compares patients who have a disease or outcome of interest (cases) with patients who do not have the disease or outcome (controls), and looks back retrospectively to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and the disease.
cross-sectional study (also known as across-sectional analysis, transversal study, prevalence study) is a type of observational study that analyses data collected from a population, or a representative subset, at a specific point in time
Effortful swallow: Increase force on the bolus, increases BOT movement reduce residue
Masako (tongue hold): increase BOT/PPW contact—this also reduces airway closure
Falsetto: strengthens muscles in larynx—protects airway
Lingual press: to improve tongue strength and endurance
EDiscuss change from clinical eval;
Oral phase:
Reduced bolus formation and control
Reduced mastication
Increased oral transit time
Issues due to reduced ROM s/p surgery
Pharyngeal phase
Reduced hyolaryngeal elevation resulting in multiple swallows
Delayed response trigger 1-2 seconds
Throat clearing present with thin liquids
Functional swallow with Nectar thick liquids through straw sips
Puree required 2 swallows
Moderate pharyngeal dysphagia
Recommendations
Dysphagia therapy 3x/week
Diet: Puree with NTL
VFSS
Patient A had a VFSS before her discharge from JRB in late summer 2016 (~2 weeks after her 1st video, ~3 weeks after surgery)
Bolus formation and control IMPROVED w/ intermittent…
PRE-therapy: Oral phase
Reduced bolus formation and control
Disorganized A-P transport
Premature spillage
mid-posterior tongue residue
Compared to pre-therapy VFSS, the things that changed;
Swallow response went from delayed 1-2 seconds to timely
Reduced hyolaryngeal excursion to grossly adequate
Decreased pharyngeal constriction (SAME)
Poor BOT and PPW approximation (SAME)
Residue present on BOT, valleculae, and posterior pharyngeal wall
Penetration/Aspiration with thin liquid—post-therapy only flash penetration with thin liquids and NO aspiration
For the pharyngeal phase her…
Penetration: Intermittently present with thins (FLASH) due to pooling in the pyriforms that enters the laryngeal vestibule because of reduced airway closure
Trial interventions: Results: helped to minimize residue, Liquid Wash--Results: helped to minimize residue and Effortful Swallow. Results: no significant changes noted from natural swallowing *did not formally test chin tuck maneuver during this exam as patient had soft cervical collar in place (she consistently wears this during meals) and this would restrict full range of motion in the neck
FCM
FCM 4/7—5/7
Had ~2 weeks of therapy (5x/week) between 1st video and 2nd
Thin liquids with strict adherence to safe swallowing strategies
tilt head forward/down with solids (as able given neck restrictions and collar in place)
cough/clear throat if pt feels something go down wrong
Chin tuck: narrows oropharynx, can help with airway protection, increased tongue pressure
-used for delayed onset
-reduced PPW/BOT approximation
-decreased airway protection/aspiration during swallow
(1) Pushes base of tongue towards pharyngeal wall
(2) Expands vallecular recesses
(3) Narrows the entrance to the laryngeal vestibule by moving the epiglottis posteriorly
VF medialization restores voice for patients with VF paralysis or weakness (PT A w/ R VF paralysis)
Received stoboscopy—R. VF immobility (VRQOL score was30/35)
Patient met ST and LTG and was discharged from dysphagia therapy in Fall 2016
MTD: technical term for stressful or strenuous overuse of the voice, resulting in vocal dysfunction
Surgery: muscle issues swelling on top of progressive neuro disease (CNS, PNS dysphagia, AND a muscle issue)
She was then re-admitted to JRB on 8/28 where she had been making progress, but was still not physically ready to return home. She was admitted to SCU on 9/16 for continued recovery and progression of mobility.
patients will be complex, and that often times the presenting diagnosis may not be the complete diagnosis. We need to be “diagnostic detectives” when evaluating our patients whether that be for swallowing, language, speech, or any other aspect of what we do…
