Mr. García was 51 years of age when he was referred as an outpatient by the director of Neurology and Rehabilitative Medicine at Municipal Hospital to the staff SLP in charge of swallowing disorders. The referral note read “myotonic dystrophy, dysarthria, dysphagia for solids.” The SLP recognized her role in ensuring the patient’s safety. Difficulty in swallowing foods could result in choking and/or aspiration pneumonia. The SLP was also concerned about the dysarthria and wondered to what degree this affected Mr. García’s communication. At their first meeting, the SLP learned that .Sø(BSDÓB B SFDFOU JNNJHSBOU GSPN $PMPNCJB IBE limited English proficiency. Once again, the SLP was grateful for her own Spanish language skills; the summer she had spent in Spain after her third year of college had been worthwhile in a multitude of ways. Many of the patients and staff at this inner- city hospital spoke Spanish as their primary language. Although Mr. García was mildly dysarthric, his speech was readily intelligible. His responses during the interview were appropriate in form (Spanish) and content. Mr. García reported that he choked on rice, a staple of his diet. Other foods and liquids did not appear to be problematic. He reported that he smoked “a little, just at the Saturday evening dances.” A cursory evaluation of the oral mechanism revealed adequate strength and motion of the lips, tongue, velum, and mandible. Although coughing, choking, and gurgling were not observed during trial feeding, an apparent delay in the pharyngeal swallow reflex was noted with both liquids and solids. The SLP recommended a modified barium swallow study to confirm and document dysphagia. Several types of foods were mixed with barium in preparation for the X-ray procedure. Mr. García ate a spoonful of applesauce and then a bite of cookie as the radiologist and the SLP watched the X-ray monitor. No difficulties were noted in the oral phase. However, they observed food lingering in the esophagus and building up with each successive swallow. Although the larynx elevated for swallowing, the bolus did not clear, and residue remained on the right vallecula and aryepiglottic fold. Mr. García was instructed to produce an abdominal cough, but he was unsuccessful, and the food remained on the fold. The SLP made the following recommendations: Mr. García should not eat alone. He should avoid clear liquids and take only a small amount of food before swallowing. He should try to cough deeply when he feels food stuck in his throat. At the next appointment, in 2 weeks, Mr. García would be instructed in the supraglottic and hard swallow techniques. Because myotonic dystrophy is a progressive disease, Mr. García requires regular monitoring.
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