Dysphagia 143The speech- language pathologist saw Kevin as an outpatient for the swallowing evaluation.
It was held in the rehabilitation wing of the hospital, but because of the risk of choking and
aspiration, it was done in a diagnostic room instead of an outpatient suite. The clinician told Kevin
about the choking and aspiration risks and wanted easy access to suction and emergency medical
personnel if necessary.
The oral- facial evaluation showed the extent of the surgeries. The left side of Kevin’s tongue
had been almost completely removed. Much of his lower jaw bone had been destroyed, and there
was scarring and indentation in his neck where muscles, glands, and tissue had been removed.
Kevin’s left lower molars and incisors were missing. Tongue mobility was limited for protrusion,
retraction, lateralization, depression, and elevation. Intrinsic tongue muscles, particularly on the
left side, were unable to adjust the shape of the tongue. Sensation was diminished throughout the
left oral-pharyngeal region.
Kevin’s voice was unremarkable, with no voice quality change. He could not perform
velopharyngeal closure to create the intraoral air pressure required to suck from a straw.
However, by placing a straw on the right side of his mouth, he could suck water from a glass.
Once the liquid was in his mouth, by keeping it to the right side, he was able to initiate a
swallow. There was no seepage through his lips or into his nasal cavity. He could initiate a
normal ref lexive and purposeful swallow without choking or coughing. He also displayed
successful oral containment, transportation, and swallowed ice chips and could manage purées
and finely chopped foods. Finely chopped meats required additional lubrication, which was
provided by sauces and gravies.
Kevin underwent plastic surgery to reduce the scarring and deformation resulting from the
cancer surgeries. Eventually, he returned to his job as a farm worker and learned to prepare meals
to accommodate his oral limitations. Five years later, the time deemed necessary for a cure, the
oral cancer had not returned.
Case Study 7-5: Isolated Dysphagia in a 47-Year-Old Man
The rehabilitation clerk gives you a message that a dysphagia evaluation has been ordered for
a 47- year- old man in the intensive care unit. On arrival, you go to the nurses’ station and ask for
Jim’s chart.
The cover page has the usual information, such as the patient’s full name, address, telephone
and Social Security numbers, primary care physician, and payment sources. You take notes
for the report you will write and are surprised at the admission diagnosis, which is simply one
word: dysphagia. This seems unusual; dysphagia generally occurs with traumatic brain injury,
cerebrovascular accident, multiple sclerosis, amyotrophic lateral sclerosis, and other serious
conditions.
You read the neurology and radiology reports to try to understand this patient’s unusual
medical predicament. They are not very helpful. The computed tomography scan shows no ce re-
bral infarcts. This is not surprising; it takes several hours, and sometimes days, for a scan to show
brain damage, and even then, small, isolated lesions may never be discovered. The neurology
report suggests that the patient is free from illness. You skim the rest of the report and focus on
“Impressions.” The neurologist believes the dysphagia may be related to undetected damage of