Clinical Scenario
Megan, a 9-year-old female, has an extensive medical history (see Appendix to view full medical history) that has led to a diagnosis of a swallowing disorder, or oropharyngeal dysphagia. Oral dysphagia can be defined as a disorder of sucking, chewing, or transferring boluses into the pharynx (American Speech-Language-Hearing Association [ASHA], 2016). Traditionally, pharyngeal dysphagia is defined as penetration or aspiration of a bolus, a mass of food or liquid, into the airway (Daniels et al., 2009). Instrumental video swallow studies were conducted at 4 and 6 years old and a fiberoptic endoscopic evaluation of swallowing (FEES) was conducted at 1 year old to evaluate Megan's swallowing. All three of these early swallow studies revealed both penetration and silent aspiration of thin liquids; in other words, Megan did not cough on thin liquids when the material entered her airway. Megan's swallowing abilities were further complicated by oral phase dysphagia, as well as respiratory and airway management issues, leading to concerns with weight gain and growth.
Recent therapy sessions have focused on the following treatments: functional oral motor movement with guided chewing, visual feedback with the use of a mirror and charts, oral care techniques to aid motor patterns for clearing mouth of residue including spitting, and a modified supraglottic swallow sequence (i.e., hold bolus, swallow, cough, swallow again). These treatments have led to progress in Megan's swallowing status by resolving oral aversion, improving chewing and bolus control, and practicing a timely initiation of swallow with solid and puree textures. However, Megan continues to demonstrate a mild delay in initiation of her swallow with thin liquids using a single-sip open cup and single-sip narrow juice box straw. Because of the progress noted in therapy, a repeat swallow study was conducted at 8 years old and revealed no penetration or aspiration. Current recommendations from her hospital-based speech-language pathologist (SLP) include a slow wean from nectar-thick liquids to 1/2 nectar thick to thin liquids using the strategies of single sips, small bolus size, and slow rate. Further recommendations include upright positioning, cues to place food on the molar surface, and chewing well as needed. Both Megan and her family have expressed a desire for Megan to live as normal a life as possible and participate in simple activities such as taking water sips from the water fountain at school with her friends. Megan's adherence to the recommendations is inconsistent. Per parental report, she often will "sneak" thin liquids and refuse thickened liquid beverages. While recent reports indicate that Megan's signs and symptoms of swallowing difficulty with oral intake are improving, she continues to cough and choke unless she "takes very small sips".
Megan's desire to drink similar liquids as her peers is not unlike many other individuals with a diagnosis of oropharyngeal dysphagia requiring extended swallowing therapy. In the pediatric hospital where Megan received speech therapy, a common recommendation for facilitating a safe swallow is a reduction in bolus size. Our research team decided to conduct a review of the external evidence to determine the level of support for the recommendation of reducing bolus size to decrease the frequency of aspiration or to eliminate it altogether.
