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292 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
in Table13–1 may eventually require treatment for
speech and/or voice problems as a result of the
swallowing examinations. When the swallowing
problem has been diagnosed and treated, and provisions are made for swallowing safety and adequate
nutrition, the aspects of the voice or communication
problem may be addressed.
Analysis of airflow and air pressure is reserved
primarily for problems related to the voice; however, the same measures may also be important in
assessing vocal fold closure, improving vocal fold
closure, and monitoring breathing function during
swallowing. Subsequent measurements of these
parameters should be documented as the patient
progresses in rehabilitation. Martin-Harris and
colleagues
4
described a system for observing and
recording apnea during swallowing. Observations
of the respiratory patterns provide the clinician with
a basis for understanding the coordination of the
respiratory and phonatory systems during swallowing as discussed in Chapter 2.
Other systems such as those described by Pitts
5,6
et al
and Laciuga et al 7 are now well known to
improve both swallowing and vocalization.
Electromyography (EMG) is becoming more
important in the diagnosis and treatment of swallowing and voice disorders. Although it is not critical to have EMG equipment available in the voice
and swallowing center, its availability eliminates
the need for a second trip to a specialist’s office.
With EMG in the office and a consulting neurologist
available, information regarding nerve function can
be obtained during the same visit, avoiding further
delays to the start of treatment.
PERSONNEL
The development of a voice and swallowing center brings together specialists who have a special
interest in the speech and swallowing organs and
expertise in the diagnosis and treatment of problems affecting these organs. SLPs who are engaged
in the diagnosis and treatment of voice and swallowing disorders should maintain contact with the
American Speech-Language-Hearing Association’s
Special Interest Divisions 3 and 13. Each division
offers special courses at the organization’s annual
convention as well as maintains websites with
access to resources, special programs, and continuing education. In the United States, not all SLPs treat
swallowing or voice disorders on a regular basis.
In some countries, the SLP is considered the voice
therapist or phoniatrician, the voice clinician, or the
dysphagia therapist, indicating special training or
extensive expertise in these areas. The American
Academy of Otolaryngology-Head and Neck Surgery has a speech and swallowing subcommittee
to monitor regulations and propose standards to
improve patient safety and clinical compliance with
existing diagnostic and treatment codes.
Many of the otolaryngologists who are fellowship trained in voice often provide the medical and
surgical leadership of the comprehensive swallowing center. Students (both speech-language pathology and medical) are encouraged to observe the
diagnostic, treatment, and overall patient management in a swallowing clinic during their training.
Nothing is as valuable as shared real-time
experience.
—Anonymous
In a comprehensive swallowing center, communication between clinicians and patient and among
clinicians is ongoing and direct. Using this clinical service delivery model, the key members are in
close proximity and interact in the testing and treatment phases of patient care. The rationale for having
all specialists in close proximity is that individuals
with different professional backgrounds can see
the same patient, conduct their tests and assessments within the same day, and communicate the
results to each other without delay. The nonsurgical
therapeutic aspects of swallowing disorders provide
unparalleled continuity of care for the patient if all
of the specialists are “in the loop.” The digital or analog media of a particular swallowing examination
allows all members of the therapeutic team to see
the same examination but attend to different aspects
as they relate to the presenting symptoms. Having
the specialists in close proximity adds to efficient
13. CASE STUDIES 293
use of everyone’s time, especially the patient’s, and
allows for shared real-time experiences during and
after the examination.
Physicians and other health care professionals
with specific areas of expertise in swallowing in
addition to an understanding of the neurophysiology of swallowing are integral to the comprehensive care of patients seen in a swallowing center. In
particular, the following physician specialties are
necessary: gastroenterology, pulmonology, neurology, psychiatry, and radiology. In addition to the
SLP, other nonphysician health care professionals
are also vitally important to deliver complete care to
patients with voice and swallowing disorders. They
include nurses, registered dieticians, physical therapists, occupational therapists, and social workers.
FACILITIES
A defined space is necessary to house the medical
and rehabilitation staff and the special equipment
used by the individuals involved in the management
of patients with swallowing disorders. Treatment
rooms should be well lit and have a decor that fits
the mission of the center. The waiting area and treatment rooms should be designed for patient comfort.
Reading materials or brochures that focus on voice,
communication, and swallowing should be available
in the waiting areas. These may be obtained from
the American Speech-Language-Hearing Association
and from the American Academy of OtolaryngologyHead and Neck Surgery.
Rooms should be large enough to accommodate
the specialists, the patients, and significant others, as
well as consultants who will come to participate in
specific portions of the examinations. Although the
swallowing center is usually located in a medical setting, the need for patient comfort and convenience
of a treatment center should not be overlooked.
CASE STUDIES FROM VOICE AND SWALLOWING CENTERS
It is not always obvious to a patient or to the referring internist if the patient’s underlying problem
will involve treatment for swallowing only or for
problems related to the voice, speech, or airway
anatomy and physiology conditions that may coexist. The value of a comprehensive swallowing center
to the referring physician is that the physician will
know that by referring the patient to a place where
a group of individuals have expertise in both areas,
the diagnostic workup will be comprehensive. The
clinicians will evaluate the patient’s complaints and
suggest an orderly treatment approach. The internist will not have to find additional resources and
will need to maintain contact with only one group.
The following cases are common examples of the
types of patients seen in a comprehensive swallowing center.
Parkinson Disease
Parkinson disease provides an excellent example
of a medical condition that illustrates the value of
a center where dysphagia, voice, and communication disorders are managed. A neurologist usually
refers these patients because of changes in the voice
or difficulty swallowing certain food consistencies,
usually solid foods. Over time, patients with Parkinson disease develop vocal weakness, dysarthria, and
ultimately begin to cough and choke when swallowing. The patient often reports a change in their voice
coinciding with the diagnosis of Parkinson disease
but may not notice changes in swallowing other
than an increase in throat clearing, excess mucus,
globus sensation, and increased cough. However, on
questioning, they may note that the cough is more
pronounced after eating lunch and dinner. If the
Reflux Symptom Index (RSI) is used, it is usually
above normal, and the Voice Handicap Index (VHI)
and the Voice Handicap Index-10 may also be above
normal.
55-year-old male with a 2-year history of Parkinson
disease. He reported a history of vocal weakness to
his primary care physician. After increased difficulty
in talking and then several months later experiencing dysarthria and choking on liquids, his primary
physician referred him to a neurologist who diagnosed Parkinson disease and referred him to the
swallowing and voice center. Based on the patient’s
symptoms of choking, weak cough, voice change,
8,9
Weight loss may be reported.
The first case is that of a patient who is a
294 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
dysphagia, coughing after meals, and his EAT-10
score of 35, a FEES examination was appropriate.
In some centers, this is done by the SLP; in others,
the otolaryngologist does it. His primary complaint
at that first visit was related to his voice. Because
of the diagnosis and the complaints of both voice
and swallowing, the FEES exam was administered.
Figure 13–1 was taken after swallowing a bolus
consisting of a cracker. The examination photo was
taken after eating a small piece of cracker coated
with green food coloring. Evidence of the remaining bolus is present along with secretions, which
the patient did not report feeling prior to the test.
The patient noted that he swallowed it com-
pletely but coughed afterward.
Video 1–3 (see Chapter 1) is a FEES examination
of a patient with a history of dysphagia. Note that
the bolus fails to completely pass into the esophagus. The problem is due to weakness in the muscles.
The patient was prescribed a proton-pump inhibitor (PPI) and referred to the SLP for swallowing
and voice therapy to improve vocal fold closure and
manage the dysarthria. The SLP also recommended
following solid foods with a sip of water (“liquid
wash-down”). The Lee Silverman Voice Treatment,
a special voice therapy for patients with Parkinson
disease,
FIGURE 13–1. Patient with diagnosis of Parkinson disease.
10
was also discussed and treatment rec-
ommended. Video 13–1 presents an example of a
patient with early Parkinson disease reporting the
feeling of food remaining in his throat. He shows
slow upper esophageal opening. Note how the
bolus moves in almost slow motion compared to
the normal subject in Video 1–2 (see Chapter 1).
Video 3–5 (see Chapter 3) presents a FEES
examination of a patient with advanced Parkinson
disease and a diagnosis of recent cerebrovascular
accident (CVA). Note the sluggish movements, the
attempts of laryngeal elevation, and eventually the
penetration that begins to occur. Video 13–1 is an
example of a patient with early Parkinson disease
reporting the feeling of food remaining in his throat.
He shows a slow upper esophageal opening. Again,
in this case the bolus moves slowly compared to the
normal subject in Video 1–2 (see Chapter 1).
In Chapter 6, we introduced expiratory muscle
strength training (EMST). This exercise technique
involves exhaling against a resistance, usually a
small device containing some type of resistance.
Although it has been used mostly for improving
speech, several investigations have suggested that it
has promise for improving swallowing as well. Rationale for the use of strength training was outlined by
Burkhead et al
11
and suggests that strength training
will increase functional muscle reserve, stimulate
recruitment of additional motor units, and prepare
the swallow organs for the rapid series of events
that will follow. Given that patients with Parkinson
disease have both a slow-acting neuromuscular system and weakness in that action, strength training
may be a reasonable approach to improving both
swallowing and voice in these patients.
Video 13–2 presents a patient with Parkinson
disease who is being treated with breathing exercises using a breath trainer. Note the early penetration and aspiration and then the cough that helps
to clear the aspirate material.
The visit to a voice and swallowing center by a
patient with Parkinson disease enables clinicians to
maximize the value of the patient’s visit and diagnose and offer a comprehensive plan of treatment
for the major problems of voice and swallowing in
one visit. The otolaryngologist and the SLP send one
report back to the referring physician that includes
the results of the history, medical examination, test
outcomes, and treatment plans.
www
www
13. CASE STUDIES 295
The organization of swallowing and voice specialists under one roof facilitates a comprehensive
diagnostic examination followed by a plan for the
necessary treatments. There is no need for timeconsuming referrals, loss of valuable examination
data, or confusion about who is treating what aspect
of the problem.
Cough and Hoarseness
Cough is a common complaint of patients seen
by an otolaryngologist. The patient may associate
the cough with eating, talking, or no specific activity. The personnel at a comprehensive swallowing
center are knowledgeable and equipped to fully
assess the patient and provide treatment. The referring physician can feel assured that by referring the
patient to a comprehensive center, the issues related
to swallowing, coughing, and hoarseness will be
addressed.
RC is a 48-year-old attorney who reported increased throat clearing and cough following surgery
for gallbladder removal. At first, he noted a raspy
voice, but then his cough increased. The cough happened mostly when talking, although more recently,
the cough was occurring when he swallowed liquids
and even at random times. His family physician prescribed an antacid that did not improve the cough or
the voice after 4 weeks. Initially, he was sent for an
MBS at an outpatient center. The report was normal
swallow with no penetration or aspiration on any of
the consistencies. His physician then referred him
to a comprehensive swallowing center. His VHI-10
was 16, above the normal value, and his RSI was
18, also above normal. Notable also was the rating of 5 for hoarseness on the RSI. Given that his
symptoms were related to his voice and also to his
swallowing, the FEES was selected as the diagnostic
test of choice. Figure 13–2 shows the vocal folds of
the 48-year-old male attorney. A left vocal process
granuloma was found.
The FEES was administered by the ENT and SLP
and revealed normal swallow followed by throat
clearing. When given several consistencies of foods
to swallow — applesauce, cracker, and an apple — he
showed no penetration, no aspiration, and no obvious delay or residual bolus in the piriform sinus or
FIGURE 13–2. Vocal folds of a patient with left vocal pro-
cess granuloma. The white areas seen may be related to the
extensive use of antibiotics, which were prescribed prior to his
current examination.
valleculae. The FEES was reported as normal swallow function. A left vocal process granuloma was
visualized.
The patient was diagnosed with a vocal process
granuloma, chronic inflammation, and laryngopharyngeal reflux (LPR) (see Figure 13–2). The results
of the diagnosis and plan of treatment were sent
to the referring physician. Following the examination, he was asked to go on voice rest for a 5-day
period since he was nearly aphonic. A modified diet
eliminating highly acid liquids and foods (caffeine,
chocolate, alcohol, pepper, spicy foods, mints, and
carbonated beverages) was proposed for 2 weeks
as a trial.
Based on the findings of the FEES and the Reflux
Finding Score (Appendix 2), the patient’s antacid
medicine was stopped, and a PPI was prescribed
twice daily, to be taken 30 to 60 minutes before
breakfast and dinner. Because of his hoarseness,
he was also referred to the SLP for vocal hygiene
and voice therapy following the voice rest period.
The SLP saw him 4 times beginning after his voice
rest period, working mostly on reducing the hard
glottal onset in his speaking pattern and counseling him as to temporary diet and lifestyle changes
necessary to treat the vocal fold granuloma and the
laryngopharyngeal reflux. This included an increase
in water consumption.
296 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
When he returned 3 months later, he noted that
his coughing associated with talking was substantially reduced. His VHI-10 was now a 5. The vocal
folds were examined via TFL, and the granuloma
was no longer visualized. His FEES exam was normal with no penetration or aspiration. Figure 13–3
shows the vocal folds at the 3-month follow-up
examination. He remained on the PPI medication
once a day and continued with 4 additional therapy
sessions. In addition, he modified his diet to limit
highly acidic foods and liquids.
Although this type of patient is often seen in
the swallowing center, the diagnosis and treatment
may not always be obvious. For example, a patient
who initially seemed similar to the patient described
in the previous paragraph was concerned about his
increasing hoarseness, which had been present for 8
to 10 months. His wife noted that he often coughed,
but it was primarily after eating or drinking or upon
waking up. An 8-pound weight loss over the past
6months was reported. His internist referred him
for evaluation of his voice. The SLP noted the pres-
FIGURE 13–4. Note the food coloring down to the level of
the vocal folds, indicating penetration of blue-colored water.
ence of a nasal quality in his speech. A complete
FEES was done. Figure 13–4 shows the result following the swallow of a nectar consistency. There was
penetration to the level of the vocal folds.
Based on the findings of the SLP (nasal speech
quality) and the swallowing examination (penetration), this patient was sent for a neurological
consultation. He was ultimately diagnosed with
amyotrophic lateral sclerosis (ALS). This case points
out the importance of obtaining a thorough case
history, selecting the proper examinations, knowing the signs and symptoms of related neurological
diseases, and then consulting other specialists when
there is a need for more answers.
In this case, the multiple findings obtained by
the SLP and ENT combined to suggest a neurological
disorder, specifically ALS. The neurologist confirmed
the diagnosis, and the patient was referred back to
the SLP for treatment of his swallowing and referred
to the ALS self-help group located in the city.
FIGURE 13–3. The vocal folds at 3-month follow-up of the
patient with the vocal process granuloma.
Zenker Diverticulum
A 64-year-old man in otherwise good health complained to his primary physician of occasional
13. CASE STUDIES 297
hoarseness, throat clearing, occasional burping,
recently a “gurgling” sound in his throat, and often
the taste of food after swallowing. Following the case
history and examination of the patient, the primary
physician offered him a 4-week course of a popular
PPI and dietary modifications. After 6 to 8 weeks,
the problem had increased in severity, his hoarseness and throat clearing were more regular, and he
indicated several episodes of regurgitation. The primary physician referred him to a voice and swallowing center, indicating in the referral letter that the
patient was hoarse and not improving despite twicedaily PPI medication, a modest 7-pound weight loss,
and discomfort due to the burping.
At the swallowing center, the patient completed
the RSI, scoring 31, and the VHI-10 with a score
of 17 and an EAT-10 score of 12. Given the report
from the family physician and the ratings of reflux
and VHI-10, it was decided to start the examination
with a TFL. On exposure of the larynx and vocal
folds, there was evidence of regurgitation. Mucus
was seen in the piriform sinus. A few sips of water
were given to the patient. Although he swallowed all
without penetration or aspiration, he regurgitated
the water. At that point, the examination was ended,
and the patient was sent for a barium esophagram to
determine if a Zenker diverticulum was present. Fig-
FIGURE 13–5. Radiographic image of Zenker diverticulum
obtained during the barium esophagram.
ure 13–5 shows the radiographic view of the Zenker
diverticulum. His PPI medication was resumed and
increased to twice daily, 30 minutes before break-
Early Laryngeal Cancer
fast and dinner. Because of his hoarse voice quality,
he was referred to the SLP for a program of vocal
hygiene and voice therapy. Voice therapy was an
appropriate referral, as this was his original complaint to his internist and continued to be a complaint of his at the swallowing center.
Ultimately, the patient was taken to surgery
for a Zenker diverticulotomy and cricopharyngeal
myotomy. His follow-up visit 10 days later included
a TFL in which the piriform sinus areas were found
to be clear of mucus. The noise associated with
his swallow was also gone, and he no longer complained of regurgitation. His RSI was now 12. At a
6-month follow-up visit, the patient was experiencing no swallowing problems and only occasional
hoarseness. His VHI-10 was a 3, and no further treatment was planned.
A 49-year-old male accountant was sent to a swallowing center by his family physician after a 4-month
history of hoarseness, a 2-month history of throat
pain while swallowing, and a 6-pound weight loss
over the previous 3 months. He saw an otolaryngologist in his hometown who prescribed an antacid and suggested voice therapy for the hoarse
voice quality. However, when the SLP conducted a
thorough clinical history and review of his symptoms, she learned that he also complained of throat
pain and difficulty swallowing grainy foods. His
history revealed that he had smoked cigarettes for
15 years and quit 7 years ago. The SLP suggested
that he seek a second opinion. He was referred to
the swallowing center by the SLP. However, because
the patient was very busy, he did not schedule the
298 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
appointment immediately. In fact, it was 10 weeks
after the first ENT visit before he was seen in the
swallowing center.
In the center, it was decided to address the
main complaint of hoarseness with a rigid stroboscopic examination following a review of his history
www
and the VHI-10, which was 24. Video 13–3 shows
the exam with the lesion on the right vocal fold. Significant edema was present, and a lesion was found
on the right true vocal fold. Vocal fold motion was
normal, as were abduction and adduction. A direct
laryngoscopy and biopsy were scheduled, and a
diagnosis of a T1 vocal fold cancer was made by the
pathologist (Figure 13–6). The FEES exam was negative for penetration and aspiration, but the patient
noted pain when swallowing a large cracker bolus.
The patient opted for radiation therapy. He was also
referred to the SLP for vocal hygiene counseling at
the start of the radiation treatment. Three weeks following treatment, he remained hoarse, with a VHI10 of 11. He continued voice therapy sessions for
6 weeks. When he was seen in the voice and swallowing center 3 months after radiation treatment
finished, the vocal folds were free of lesions. His
VHI-10 was 4. He noted that he could now return to
full-time practice without vocal fatigue or significant
hoarseness. Regular follow-up examinations were
scheduled in the swallowing center. The follow-up
visits included an examination by the otolaryngologist and voice assessment by the SLP.
This case highlights the importance of the need
for a comprehensive examination when a patient
who is currently smoking or who has smoked in
the past complains of hoarseness lasting more than
2 weeks. The SLP was correct in sending the patient
back to his primary care doctor for a referral for a
second opinion from a comprehensive swallowing
and voice center. Small lesions on the vocal folds
may not be apparent on direct observation. With the
proper equipment to observe, record, and archive
the examination, the otolaryngologist, the SLP, and
the patient together can review the details of the
examination and develop a plan of treatment without delay. In this case, there was considerable delay
from the first visit to the internist followed by referral to an otolaryngologist, then the SLP, and finally
the voice and swallowing center. Because of schedules and, to some extent, procrastination, it took
nearly 3 months to obtain a definitive diagnosis.
Dysphagia and Vocal Fold Paralysis
The onset of vocal fold paralysis may follow surgery or may develop along with multiple neuropathies. The patient may complain of weak voice,
vocal fatigue, difficulty swallowing, or occasional
cough after swallowing. Figure 13–7 shows the
vocal folds of a 67-year-old male with a 14-month
history of vocal fatigue following coronary bypass
FIGURE 13–6. A 49-year-old male patient following biopsy of
right true vocal fold. The diagnosis was T1 vocal fold cancer.
FIGURE 13–7. A 67-year-old male with a left vocal fold paraly-
sis.
13. CASE STUDIES 299
surgery. Prior to his surgery, he spoke extensively
as a trial lawyer. For the 3 months prior to his visit,
he reported an increase in coughing and occasional
choking on liquids. He had been previously seen for
2 sessions of swallowing therapy in a rehabilitation
center, which he noted had been helpful, but he still
complained of vocal fatigue. His voice was breathy,
and his maximum phonation time was 9.5 seconds.
An MBS and a FEES test were done at previous institutions. Neither exam revealed penetration or aspiration, according to the written reports. He noted
that when he was “careful,” he could swallow small
amounts of liquid without difficulty. During the current FEES examination, the patient also swallowed
small amounts of liquids without difficulty; however, when challenged with repeated swallows, he
began to cough. Trace amounts of liquid were seen
at the level of the vocal folds. He indicated that on
both previous tests, he was never challenged with
repeated sips of liquid. Both previous tests were
stopped after small amounts of liquid were swallowed successfully.
This patient was diagnosed with vocal fold paresis by the otolaryngologist. Because the patient had
a weak voice and was experiencing aspiration, the
recommended treatment for this patient was a vocal
fold augmentation. This was done in the office with
calcium hydroxyapatite. The goal was to increase
his overall voice production and reduce penetration and aspiration through vocal fold approximation. Following his surgery, he reported improved
swallowing and little or no coughing. He was seen
for 4 sessions of swallowing therapy that included
exercises to improve vocal fold closure and instruction to continue to use safe swallowing techniques.
Three months after surgery, his maximum phonation time increased to 15.5 seconds, and he was no
longer coughing on liquids or solid food.
This case is an example of a team approach for
both diagnosis and combined surgical and behavioral treatments. The SLP was part of the overall
assessment process and realized that long-term
voice or swallowing therapy would not be sufficient
to treat the patient based on the findings of the voice
and swallowing assessments. He was treated with a
vocal fold augmentation procedure. This procedure
resulted in improved closure of the vocal folds not
only for swallowing but also for speaking. His voice
became louder following the procedure. Following
vocal fold augmentation, he reported that his voice
improved. His VHI-10 went from 21 to 6, and swallowing solids and liquids was no longer a problem.
Late Effects of Radiation Therapy
in the Head and Neck Region
Radiation therapy (XRT) has been increasing in frequency for the treatment of cancer in the head and
neck region. It is used as a single treatment in many
cases, such as nasopharyngeal cancer, but it is more
commonly used as a secondary treatment in other
regions of the head and neck. During the course
and for several weeks following radiation therapy,
patients experience fatigue, mucositis, dysphagia,
dysarthria, and dysphonia. This results in a decrease
in quality of life following treatment. These changes
are well known, and with adequate care, proper
nutrition, and rest, recovery from the XRT treatment
regimen slowly occurs. Of course, depending on
whether or not surgery preceded the XRT, some
problems related to swallowing and speech may
remain for a lifetime. Video 13–4 presents a patient
following radiation therapy for an oral pharyngeal
cancer. Note the vocal folds and the lack of mobile
tissue in the exam. He can no longer elevate the
vocal folds due to the fibrosis effect of the radiation
treatments.
Patients who have undergone XRT only for
tumors of the oral cavity, larynx, and pharynx have
been reporting increasing problems swallowing 3 to
5 years after successful treatment of their primary
disease. Several studies have examined late effects of
XRT. Suarez-Cunqueiro and colleagues
patients and reported speech problems in 63.8%;
swallowing problems were reported by 75.4% of
the group studied. The variables that presented a
significant association with speech and swallowing
impairment were gender, tumor location, stage of
tumor, treatment modality, and reconstruction type.
For patients who underwent XRT only, Langendijk
examined the later effects of treatment for various
head and neck tumors and found that late radiation-induced toxicity, particularly in swallowing and
xerostomia, have a significant impact on the more
general dimensions of quality of life. These findings
12
studied 851
13
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300 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
suggested that the development of new radiationinduced delivery techniques should focus on reduction of the dose not only to the salivary glands but
also to the anatomical structures that are involved
in swallowing.
JW is a 65-year-old male who underwent radiation therapy for an early-stage oral cancer. He completed 30 sessions of radiation therapy over a 6-week
period, a total of 70 cGy approximately 6 weeks
ago. Over the course of treatment, he suffered minor
mucositis and a 9-pound weight loss. His speech
was only mildly distorted and gradually improved
over the next 6 weeks. He maintained his nutrition on liquid supplements. Approximately 6 weeks
following the completion of radiation therapy, he
underwent a FEES examination that was reported to
be normal, with no penetration or aspiration of liquids or foods. Eventually, JW went back to work as
an accountant. He maintained his regular visits with
his oncologist and his otolaryngologist at 6-month
intervals. At 3 years post radiation, he was seen
for a regular visit with his oncologist, who noted a
5-pound weight loss since his last visit. Also noted
was excessive throat clearing. The patient reported
that he was having some difficulty swallowing foods
even when he chewed carefully. He completed the
RSI, with a rating 14, and the EAT-10 with a score
of 22, above the normal range and suggestive of
laryngopharyngeal reflux. In addition, he was given
the MD Anderson Dysphagia Inventory (see Chapter
5), and the results showed that his swallowing was
having an impact on his quality of life.
He subsequently was seen by his otolaryngologist, and following a comprehensive head and
neck examination, a FEES examination was ordered.
When the SLP and the otolaryngologist saw him for
the FEES examination, there was mild dysarthria
(distortions of /k, g, l, r/ and posterior vowels). His
cough was strong, and his voice was loud, but he
remained with severe hoarseness and moderately
severe breathiness. Figure 13–8 shows a still photo
of the exam following a 10-cc bolus of honey-thickened liquid. The FEES examination was interpreted
as penetration, minimal aspiration followed by a
cough, and pooling of the material in the piriform
sinus and the valleculae. On 4 subsequent swallows, a chin tuck, a Mendelsohn maneuver, a head
tilt backward, and a smaller bolus were tried. Only
FIGURE 13–8. The late effects of radiation therapy toxicity
in a patient (JW).
the Mendelsohn maneuver improved the swallow,
showing less residual material in the piriform sinus
with 2 swallows. A subsequent computed tomography scan failed to identify additional cancer, and JW
was told that he was experiencing late-stage toxicity
from radiation that he completed 3 years before.
The swallowing problem that JW was now
experiencing is due primarily to radionecrosis.
There may also be loss of taste, continually decreasing salivary function, and dehydration.
14
Laryngeal
radionecrosis is a late complication of radiation
therapy. It is associated with hoarseness, edema,
pain, weight loss, and upper airway obstruction. The
medical treatment options are limited, and in severe
cases, the patient may require tracheostomy or laryngectomy. It is not uncommon for the patient to
feel “better” 6 to 8 weeks after the completion of
XRT and thus want to go on with their life away
from day-to-day medical involvement; however, it is
necessary to confront the issues of late toxicity and
consider a long-term program of speech and swallow management. There is little data to suggest that a
long-term program of speech and swallow exercises
will help, but patients should be encouraged to continue to practice exercises that improve speech and
swallowing. These exercises include tongue and jaw
range-of-motion exercises and chewing exercises.
All of the exercises should be directed to improve
13. CASE STUDIES 301
motion since radionecrosis implies scarring of tissues. A hygiene program of brushing teeth 3times
daily, maintaining hydration, avoiding drying foods
and liquids, and of course avoiding cigarette smoking is recommended.
The role of the SLP has not yet been fully outlined for these patients; however, as more and more
patients with late effects of radiation are seen, a
greater awareness is building in the long-term care
of patients who have undergone XRT. We cannot say
if JW would be speaking and swallowing better if
he continued range-of-motion exercises and regular
follow-up appointments with his SLP, but additional
research may lead to evidence to support this type
of treatment.
This case describes the late effects of XRT,
which includes both severe speech and swallowing
problems. It remains to be seen how these cases will
be treated in the future, but based on general principles of muscle physiology and exercise, it might
be expected that patients can experience less severe
late complications of radiation therapy if an aggressive exercise program for speech and swallowing
is undertaken shortly after recovery from the XRT
treatment toxicity and continued for a longer period
of time. Newer radiation treatment protocols that
were described in Chapter 3, specifically intensity
modulated radiation therapy, may help to reduce the
side effects of the treatment.
Failure to Thrive in an Autistic Child
A 31-month-old child was taken to a pediatrician
because he was refusing to eat. An extensive his-
tory revealed that the child had a history of refusing
to eat in the past but eventually began to eat. His
mother described several interesting new behaviors. For approximately 6 months, he has pushed
his food away from the table, spitting it out when
he did eat it, and would run away from the table
when his mother tried to place him in a high chair.
He would often go to his room or another room in
the house and start stacking books in a neat pile or
taking his toys out of his toy box and lining them
up on the floor and then replacing them in the toy
box. The mother reported that recently, he would
not answer her with yes or no responses. He would
no longer smile when his father came home from
work; he kept his head down and looked away from
people when they talked to him. The pediatrician
referred the child to the SLP because his language
and speech also seemed inappropriate for his age.
Table 13–2 reports the child’s profile as reported
by his parents.
The child was not cooperative when the SLP
attempted to do an oral-motor examination. However, when the child was shown a series of pictures
of animals, he began to stack the pictures in the
corner of the room. The therapist then began to
show him pictures of various parts of the body, face,
hands, and so forth. When she showed him a picture
that emphasized the stomach, the child turned the
picture over and ran out of the room. A picture of a
dog and a stuffed animal dog brought him back into
the room. Then, the therapist began again to show
him pictures, and they made 2 stacks — animals on
one side and pictures of faces on the other side.
They began to name the pictures. When she showed
the picture to him emphasizing the stomach, the boy
TABLE 13–2. Patient Characteristics Reported by Parents
Age
(months)
18 22 Single-word responses Occasional smile
24 24 Repeated single-word
30 25 No 2-word responses No smiles
31 25 Single-word responses Shrieks; no eye contact
Weight
(pounds) Speech Other Behavior Noted
Rare 2-word sentences
responses