Question
I am currently seeing a patient who is tube fed. He has an immobile epiglottis, pacemaker, lung nodules, right vocal cord paralysis and cancer in his right leg. MBS showed severe aspiration and a totally immobile epiglottis. Because of physical and medi
Answer
The information provided about the patient is insufficient to make suggestions on appropriate therapy techniques. Describing the epiglottis as "totally immobile" is not informative because the epiglottis does not move independent from other structures. Typically when the epiglottis is not inverting, it is largely due to limited laryngeal elevation and anterior movement of the hyolaryngeal complex, with a small part of the final tipping of the epiglottis caused by the force of the bolus passing over it. So if one had to guess what the impaired physiology was from this symptom (i.e. epiglottis not moving), one would guess the patient needs to work on laryngeal elevation and anterior movement. However, if the patient is also known to have a paralyzed vocal fold, it is important to know if the patient has decreased laryngeal closure during the swallow which might also need treatment.
Exercises for laryngeal elevation include Mendelsohn maneuver and falsetto. For anterior movement, the Shaker exercise is appropriate. For closure, supraglottic swallow, breath hold and perhaps even hard glottal attack are recommended. However, this example points out the importance of describing impaired physiology and not the symptom. That is, from an instrumental study one needs to observe the actual physiology, not the symptom that results from the impairment. That is the only way to accurately choose treatment techniques.
Nancy Swigert, M.A., CCC/SLP, BRS-S is the Director of Speech-Language Pathology and Respiratory Care at Central Baptist Hospital in Lexington, KY. She is also Chair of the ASHA Health Care Economics Committee.
