SLT - Adult Videofluoroscopic Swallow Study Report (VFSS)

Speech and Language Therapy Videofluoroscopic Swallow Study Report (VFSS) Background Information Medical History - History of cerebrovascular accident (CVA) six months prior. - Diagnosed with Type 2 Diabetes Mellitus, managed with oral medication. - Mild cognitive impairment noted during recent neurological assessment. Baseline Diet Mrs. Evelyn Reed normally consumes a regular diet with thin fluids. She typically enjoys a variety of solid foods, including meats, vegetables, and breads. Her fluid intake primarily consists of water, tea, and occasional fruit juice throughout the day. Relevant Swallowing History Mrs. Evelyn Reed presents with subjective complaints of occasional coughing and throat clearing during meals, particularly with thin liquids. She reports feeling food sometimes 'sticking' in her throat. She underwent a clinical swallow assessment with a Speech and Language Therapist three months ago, which highlighted some oral phase difficulties and a delayed pharyngeal swallow. There is also a history of pneumonia six weeks post-CVA, which was suspected to be aspiration-related. This primarily led to the recommendation for the current videofluoroscopic swallow study. Results Mrs. Evelyn Reed demonstrated evidence of mild oral dysphagia, characterised by reduced mastication efficiency and some premature spillage of bolus into the pharynx. This was observed during the consumption of solid textures. She exhibited a delayed pharyngeal swallow initiation, with the bolus head reaching the valleculae before the onset of the pharyngeal swallow. There is also reduced pharyngeal contraction, leading to residue in the valleculae and pyriform sinuses, particularly after consuming thin liquids. This primarily resulted in instances of laryngeal penetration with thin fluids, reaching just above the vocal folds. There were no overt signs of aspiration during the study. Oesophageal dysphagia was not directly assessed during this videofluoroscopic study, but no gross abnormalities were noted in the brief oesophageal transit observed. Structural abnormalities noted: Mrs. Evelyn Reed presented with mild anterior osteophytes on the cervical spine, which did not appear to significantly impede bolus flow or pharyngeal wall movement during the assessment. There were no other anatomical abnormalities observed that would directly contribute to her dysphagia. Summary of key findings Mrs. Evelyn Reed has difficulty chewing her food and sometimes food goes into her throat too early. She also has a slightly slower reflex to swallow, and the muscles in her throat are not squeezing as strongly as they should. This means that fluids entering the airway, particularly thin drinks, can sometimes get close to her vocal cords, but did not go past them into the lungs during the study. There is residue left in parts of her throat after swallowing. These findings help us understand why she experiences coughing and a feeling of food getting stuck. Recommendations and Plan Diet: Soft and bite-sized solids with added moisture, such as sauces or gravies. Fluids: Mildly thick fluids (Level 2: Moderately Thick) using a thickening agent. Medications: To be crushed and mixed with puree consistency food or mildly thick fluid. Compensatory Strategies: Small sips of fluid, taking a second swallow after each mouthful, and tucking the chin down when swallowing to protect the airway. Education provided: The findings of the VFSS, including the risks of aspiration with thin fluids and the rationale for recommended diet and fluid modifications, were explained to Mrs. Reed and her daughter immediately after the study. A follow-up discussion will occur in the clinic. Dysphagia Rehabilitation: Daily pharyngeal strengthening exercises, including Mendelsohn manoeuvre and effortful swallows, to be completed 10 times, 3 sets per day. SLT follow up: Review in 4-6 weeks to reassess swallowing function and compliance with strategies and exercises. Referrals Recommended: Referral to a Dietitian for nutritional assessment and ongoing support for dietary modifications.