Subclinical Findings of Aspiration on Modified Barium Swallow (MBS) in an Elderly Patient Tolerating Oral Intake - Determining Best Course of Action: A Case Report

Case Diagnosis: 75-year-old female with severe oropharyngeal dysphagia following left MCA stroke.

Case Description or Program Description: Patient sustained a left MCA stroke with severe mixed aphasia and dysphagia. In acute care, patient remained NPO. Fiberoptic Evaluation of Swallow (FEES) day 7 revealed moderate to severe oropharyngeal dysphagia with aspiration of pureed and honey thick liquids. FEES day 16 revealed no laryngeal penetration/aspiration of pureed foods and trace aspiration of honey thick liquids. Patient was placed on a pureed diet, honey thick liquids via spoon, and referred for acute rehabilitation. Despite dysphagia therapy, a video fluoroscopic study (VFS) performed day 34 revealed severe oropharyngeal dysphagia with penetration and trace silent aspiration of honey consistency liquids and pureed foods. Clinically, patient was tolerating her dysphagia diet well with adequate intake and no evidence of aspiration pneumonitis/pneumonia. The decision whether to transition to a gastrostomy tube with enteral feeds was complicated by several factors including impaired capacity for decision making, high procedure risk in the setting of pressure-dependent cerebrovascular disease, and severity of oropharyngeal dysphagia on VFS.

Setting: Acute Inpatient Rehabilitation

Assessment/Results: The decision was made to place a gastrostomy tube with approval of a surrogate decision maker. The patient tolerated the procedure and was made NPO.

Discussion (relevance): This case highlights the complexity of decision-making for a patient tolerating a modified consistency diet well but with objective swallow studies demonstrating severe oropharyngeal dysphagia. The clinical team must account for the risk of aspiration pneumonia, procedure risk, impact on quality of life, and disposition of the patient when making these challenging determinations.

Conclusions: Risk of aspiration pneumonitis/pneumonia does not always correlate clinically with findings on VFS and FEES. The rehabilitation team must consider the implications of positive findings on the management of patients in the context of other highly relevant clinical variables.