“Unexpected Consequence of Effortful Swallowing:
Case Study Report”
Authors: Jane Mertz Garcia, Mark Hakel, Cathy Lazarus
<Summary by Katherine Duncan>
This case study report focused on a 12 year old (patient “SK”) with severe oropharyngeal dysphagia following a surgery to remove a brainstem tumor. Most noticeable was the absence of a pharyngeal swallowing phase, also described as no trigger of swallow within 30 seconds of bolus propulsion into the pharynx. The treatment history showed many different time period progressions of therapy. Initially, the treatment focused on lingual strengthening, bolus control exercises, and strategies to trigger a strong pharyngeal swallow. SK was still consistently showing nasal back-flow with all liquid swallows, even 10 months post-op. Another barium swallow at 13 month post-surgery showed that in fact the hard “effortful” swallow had possibly changed the mechanics of this swallow. He appeared to make tongue base contact with the posterior pharyngeal wall while the bolus was still in the oral cavity. With the pharynx blocked there was no velopharyngeal seal allowing the bolus to flow freely resulting in nasal back-flow. More studies showed that the tongue base issue was actually the main cause of the nasal back-flow, and to address it, the effortful swallow had to be discontinued immediately. He had to relearn a normal swallow, with an emphasis on effortless swallowing. Nasal back-flow steadily declined and after 14 weeks, all nasal back-flow of small boluses was eliminated for all liquid types.
Important aspect for the SLP to consider:
This study showed how important it is to carefully monitor the use of interventions, such as swallowing maneuvers, because patients could adapt in ways not anticipated.
Why did effortful swallow cause this unexpected consequence in this particular case?
Even though effortful swallow has be described as an easy and effective swallowing maneuver for all ages - instructions can be misinterpreted. Swallowing maneuvers alter timing and with patient SK, it altered the tongue base timing in a negative way. Another possible reason for the unexpected results is that most research focuses on the effects for healthy adults or those with impaired swallowing. LIttle is known about the effects with younger children.
" Unexpected consequence of effortful swallowing: case study report". Journal of Medical Speech - Language Pathology. FindArticles.com. 02 April, 2009. http://findarticles.com/p/articles/mi_hb1397/is_2_12/ai_n29102543/
Posted by Katherine Duncan