VE was performed 1 day after admission. No aspiration occurred during swallowing, and no post-swallow residue using honey-thickened liquid and jelly was observed. However, post-swallow oral residue mixed with saliva was delayed moving downward to the hypopharynx , leading to aspiration. The dysphagia severity scale (DSS ) score was 2.

During the next 2 days, the patient was investigated by VF . The VF findings are shown in Table 9.1 and Fig. 9.3).

The first VF study (Table 9.1) showed that the change in the reclining angle had a beneficial effect on bolus control in the oral cavity. The 60° reclining posture contributed to the improvement in oral function by minimizing the duration of bolus manipulation when compared with the 45° reclining posture. All bolus consistencies and textures , including the honey-thickened liquid , nectar-thickened liquid , thin liquid , jelly , and rice porridge , showed the same trend: no penetration , aspiration, or pharyngeal residue in either the pyriform sinus or vallecula . Mild dysfunction of esophageal transition was noted.

The main problems found in the first VF study were the presence of oral residue after swallowing and poor bolus manipulation . Upon returning to the ward, a large amount of sputum mixed with a barium bolus was suctioned from the tracheostomy tube. This indicated the presence of food aspiration , most likely from oral food stasis after the VF study. Although there was no clear evidence of penetration or aspiration during the VF study, the 10 ml thin liquid , cup drinking , and eating a two-phase food were not tested to ensure safety. Thus, the DSS score was 2 (food aspiration ).

Based on the outcomes of VF and VE , the main physical finding was oral residue , and the physiological abnormality was poor bolus control (both bolus formation and propulsion) secondary to orolingual weakness and dysfunction. This resulted in delayed post-swallow aspiration, as mentioned earlier (Table 9.2).

Initial treatment involved nutritional support, mainly via an NG tube. A SLHT started target-oriented swallowing exercises once a day (lunch time) with nectar-thickened liquid , jelly -type rice porridge , and chopped softened food with thickened liquid at a 60° reclining position. Oromotor exercises including lip exercises, tongue movement exercises (forward-protrusion, left-right side, tongue tip elevation), and tongue strengthening exercises using the Pecopanda tool (JMS, Hiroshima, Japan) were performed as element-based exercises . Additionally, chewing exercises were recommended simultaneously with intensive pulmonary rehabilitation by a physical therapist . Table 9.3 summarizes the treatments performed based on the physiological abnormalities found.

A speech-type valve with a deflated tracheostomy tube cuff was periodically used to control saliva aspiration and perform phonation training. Two days after starting target-oriented training with modified food, the patient developed a low-grade fever without other symptoms, and eating training was temporarily discontinued. Meanwhile, the element-based exercises were continued. The patient’s medical condition was generally stable. No increased amount of secretion or leukocytosis was found. The C-reactive protein concentration was slightly rising, however, and a chest radiograph showed mild consolidation in the right lower lobe. The most likely diagnosis was aspiration of saliva , not food. Therefore, the eating training performed by the SLHT was carefully resumed, and the tracheostomy tube cuff was inflated during training. The ward nurse also collaborated with the SLHT to closely observe the patient after meals.

After a 9-day course of swallowing rehabilitation, the antiepileptic drug was stopped; this improved the patient’s level of arousal. The patient was able to incrementally increase his cooperate with the swallowing training. His fever gradually resolved along with his improved clinical status, and his blood test results were within normal limits during the following 10 days. In addition, amantadine was started to further promote his swallowing ability (initial dosage, 50 mg/day with a subsequent increase to 100 mg/day in the next week).

The patient’s swallowing ability progressively improved, and the NG tube was removed when he was able to ingest three adequately sized meals a day 1 month post-training. Additionally, his secretion status was greatly improved, and the tracheostomy was eventually removed. The RSST score, MWST score, and tongue pressure were 4, 5, and 22.2 ± 2.1 kPa, respectively.

Follow-up VF was performed on day 37 after the first VF study to observe the changes in the patient’s abnormal physiology and his response to the rehabilitation treatment (Table 9.4).

Various types of boluses were used during the repeated VF studies to clarify the patient’s swallowing ability and clinical improvement. The results showed improvement in his oral function (either bolus formation or propulsion) and decreased oral residue after swallowing. His chewing ability seemed improved compared with the first VF study. However, when chewing food such as corned beef and two-phase food and when drinking a large amount of liquid, orolingual weakness with coordination dysfunction was still observed. Continuation of all exercises was thus recommended with a gradual increase in intensity.

The DSS score was 4 (occasional aspiration ). Diet modification was slowly performed in a stepwise manner until ordinary porridge and soft food could be ingested while continuing the nectar-thickened liquid because the risk of thin liquid aspiration still remained. The RSST , MWST , and tongue pressure measurement were repeated, and the results indicated improvements in the swallow ability (4, 5, and 24.8 ± 1.7 kPa, respectively). After 2 months of continuous swallowing training, VF study was repeated.

The results of the third VF study (Table 9.5) demonstrated improved swallowing ability, particularly in bolus manipulation , chewing ability, and orolingual control. The oral residue was still present, although it was decreased. Liquid cup drinking resulted in no deep penetration as detected at the second VF study. The DSS score had changed to 6 (minimum problem).

The patient’s diet was altered in a stepwise manner to soft food, soft rice, and liquid without the use of a thickener . Finally, the patient was able to swallow regular food independently. Therefore, his physiological abnormalities had definitely improved by either spontaneous recovery or the improvement in his consciousness in addition to the effectiveness of swallowing rehabilitation. The progression of the DSS score, eating status scale (E SS) score, and treatment is summarized in Table 9.6.

Eleven months after the onset of hemorrhage , the patient developed recurrent aspiration pneumonia every time he initiated direct exercise ; therefore, oral intake could not be started. However, he achieved the goal of a regular diet 59 days after admission to FHUH. The success of this case illustrates the importance of detailed evaluations of all swallowing components and performance of a systematic intervention. The patient’s abnormalities can be summarized as follows:

A transdisciplinary approach is important in swallowing treatment. Symptoms of aspiration pneumonia should be considered as an indication to proceed with treatment. Clinicians must engage in discussions with SLHTs and nurses regarding the patient’s symptoms (e.g., fever, amount of expectoration ) and whether these are early signs of severe pneumonia or if the patient can continue their exercises, as well as how to adjust the exercise prescription. SLHTs and nurses should regularly evaluate the effects of the swallowing exercises , particularly at the time of step-up. Finally, SLHTs and nurses must always observe the patient for symptoms of aspiration pneumonia and report any remarkable findings to the doctors.