When One Imaging Study Is Not Sufficient—A Case Study
“Michelle,” a 48-year-old woman, was admitted to the hospital following a gas explosion. She had suffered second- and third-degree burns all over her body as well as inhalation injuries to the mucosa of her mouth and her upper airway.
Over the course of her stay, Michelle required multiple skin grafts. This treatment necessitated general anesthesia, causing further irritation to her vocal folds. Additionally, she required parenteral feeding, and after seven days, a nasogastric tube was placed. Even with the tube, the severity of her burn injuries still compromised her nutritional status.
After 18 days of hospitalization, a swallowing evaluation was requested for Michelle.
Now what?
Imaging Study #1—Fiberoptic Endoscopy
Due to the fragility of Michelle’s medical status, the hospital’s SLP team determined that the most prudent option was a clinical exam accompanied by fiberoptic endoscopy to evaluate her upper airway during swallow attempts.
You can see the results of the fiberoptic endoscopy below.
The study revealed heavy, copious secretions in the pharynx. These secretions were partially cleared as Michelle attempted swallowing efforts. When the endoscopy looked at the vocal cords, they appeared to be intact, but it was difficult for the team to determine conclusively if she was protecting her airway.
As the study continued, Michelle became fatigued, and she refused to allow further observation of her attempted swallows. Unfortunately, the study ended without sufficient information to determine whether Michelle could begin oral feeding.
Imaging Study #2—Modified Barium Swallow Study
The combination of ongoing tube-feeding and the severity of Michelle’s burns led to continued deterioration of her nutritional status. The pressure was on to transition Michelle to oral feeding.
Her SLP team decided to schedule Michelle for a modified barium swallow study even though moving her from the burn unit to radiology would be challenging.
You can view the results from the modified barium swallow study below.
While the results from this study were not completely normal, they did show that Michelle could swallow safely, allowing her physicians to switch her over to a modified oral diet. Without this secondary study, Michelle might have remained on tube feeding with nothing by mouth, ultimately delaying her final recovery.
Two weeks later, Michelle was discharged from the hospital eating a regular diet. While she will need ongoing rehabilitation to help her recover from her injuries, her ability to eat a regular, healthy diet will help her maintain her nutritional status so she can have the best possible outcome.
This positive outcome might not have occurred if her SLP team had not gone ahead with the second study and had relied solely on the inconclusive results of the first. While moving her for the second study posed challenges, keeping her on tube feeds was proving to be far too detrimental to her recovery.
Like other healthcare practitioners, SLPs are often under pressure to reduce costs and limit testing. A great deal of literature alludes to the potential consequences to the patient when overtesting occurs. SLPs must carefully analyze each situation on a case-by-case basis to make the right choice for each individual patient.
- Dubose, C. M., Groher, M. G., Mann, G. C., & Mozingo, D. W. (2005). Pattern of dysphagia recovery after thermal burn injury. Journal of Burn Care & Rehabilitation, 26(3): 233-7.
- Rumbach, A. F., Ward, E. C., Cornwall, P. L., Bassett, L. V., & Muller, M. J. (2012). Physiological characteristics of dysphagia following thermal burn injury. Dysphagia, 27(3): 270-83.
- Rumbach, A. F., Ward, E. C., Cornwall, P. L., Bassett, L. V., & Muller, M. J. (2012). Clinical progression and outcome of dysphagia following thermal burn injury: a prospective cohort study. Journal of Burn Care & Rehabilitation, 33(3): 336-46.
