MISCELLANEOUS |
10.5005/ijpmr-30-1-26 |
Rehab Challenge
A 60-yr-old nondiabetic, nonhypertensive male from lower socioeconomic class who is a known case of RA with irregular intake of steroid and NSAIDs for two years presented with sudden onset swallowing difficulty to both solid and liquid including saliva with nasal regurgitation and aspiration of food, associated with hoarseness and nasal intonation of voice since two years. There were no history of altered sensorium, seizure, vomiting, weakness of limbs, bladder and bowel disorder, prolonged fever, cough, trauma, contact with TB and other constitutional symptoms.
On neurological examination, there was no focal neurological deficit apart from right sided uvular deviation, asymmetry of palatal arch and absent swallowing and gag reflex. CT scan of brain was normal (Fig. 1) and he was already on nasogastric tube for long time and losing weight everyday (Fig. 2). MRI showed hyperacute infarction at left posterolateral aspect of medulla oblongata (Fig. 3).
Hence, he was diagnosed as Brainstem ischemic stroke. There after Video fluoroscopic assessment was done, which showed severe cricopharyngeal spasm (Fig. 4). Swallowing manoeuvre and dysphagia diet during Videofluoroscopic imaging failed to demonstrate any significant change in swallowing. On top of that there was aspiration on right lower lobe of the lung.
Please give your opinion regarding further management of swallowing rehab of this patient.
Fig. 1: Normal CT scan of brain
Fig. 2: Patient on nasogastric tube for long time and losing weight
Fig. 3: Hyperacute infarction at left posterolateral aspect of medulla oblongata
Figs 4A and B: Severe cricopharyngeal spasm
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