Dysphagia Knowledge Hub — 吞嚥困難知識庫

Case Study 1: Mild Dysphagia in a 72-Year-Old Woman

Patient Presentation

Mrs. L is a 72-year-old retired schoolteacher referred to the outpatient speech-language therapy clinic by her general practitioner. She reports a 6-month history of food “sticking” in her throat when eating solid foods, particularly bread, rice, and raw vegetables. She has also noticed occasional coughing when drinking thin liquids, especially in the mornings.

She denies weight loss, recurrent chest infections, or pain on swallowing. She lives independently with her husband, cooks her own meals, and continues to socialise over meals with friends. She is concerned about the coughing in public.

Past medical history: Hypertension (well-controlled on amlodipine), osteoarthritis. No history of stroke, neurological disease, or head and neck cancer.

Current medications: Amlodipine 5 mg, calcium + vitamin D supplement.

Nutrition: BMI 22.5 kg/m². No recent weight change reported.

Initial Screening Findings

EAT-10 (self-completed in clinic waiting room):

Item 3 (swallowing liquids takes extra effort): 1
Item 4 (swallowing solids takes extra effort): 3
Item 7 (pleasure of eating affected): 2
Item 8 (food sticks in throat): 3
Item 9 (I cough when I eat): 2
All other items: 0
Total: 11 — moderate risk; urgent SLT evaluation appropriate

Water Swallow Test (50 mL, Kubota):

Drank in 3 swallows over 9 seconds
Single cough 15 seconds after completion; mild throat clearing
Voice quality: slight wetness on “ah” immediately post-swallow
Kubota Grade 3 (abnormal)

Clinical Swallowing Examination

The SLT conducted a full clinical swallowing examination (CSE), supplemented by a brief GUSS-style progressive consistency challenge.

Observations:

Good posture and head control; sits upright unaided
Lip closure adequate; tongue movements within functional range for age
Laryngeal elevation: palpable but slightly reduced excursion
Mild coughing on thin liquids (3 mL trials × 3); no coughing on thickened (mildly thick) liquids or semi-solid yoghurt
Soft bread trial: 2 swallows required; occasional post-swallow throat clearing

GUSS score: Part 1 = 5/5; Part 2 semi-solid = 5/5; liquid = 3/5 (coughing on thin, no cough on thickened); solid = 4/5. Total GUSS = 17/20 — mild dysphagia

VFSS Decision

Given the mild clinical picture, clear history, absence of red flags (weight loss, aspiration pneumonia, progressive neurological symptoms), and Mrs. L’s intact cough response, VFSS was deferred in favour of empirical trial of texture modification with clear safety-netting criteria for urgent VFSS referral if:

Recurrent chest infections develop
Weight loss >2 kg in 4 weeks
Increasing cough frequency
EAT-10 increases to >15

Management Plan

Dietary prescription:

IDDSI Level 6 (Soft & Bite-Sized) diet — no bread crusts, avoid raw fibrous vegetables, cut meat to ≤1.5 cm pieces
IDDSI Level 2 (Mildly Thick) liquids for all drinks

Rehabilitation exercises:

Effortful swallow technique: 2 sets × 10 repetitions daily
Shaker head-lift exercise: 3 sets daily (modified for 72-year-old; no full Shaker due to cervical arthritis — used Chin Tuck Against Resistance [CTAR] instead)
Education on compensatory strategies: alternate liquid and solid, small bites, focused mealtimes without distraction

Caregiver / self-management education:

IDDSI Level 2 thickener preparation at home using commercially available xanthan gum-based product
Demonstrated IDDSI Flow Test with syringe; checked understanding of correct thickness
Handed written IDDSI food list and red flag symptoms card

3-Month Outcome

At 3-month review:

EAT-10 score reduced to 4 (from 11)
No episodes of aspiration pneumonia
Coughing with liquids now occasional (1–2 episodes/week vs. daily)
Weight stable
FOIS advanced from Level 5 (multiple consistencies with special preparation) to Level 6 (multiple consistencies, no special preparation but specific food limitations)
Decision: continue IDDSI Level 2 liquids; trial IDDSI Level 6 diet without restrictions. Repeat WST in 3 months; VFSS if not further improved.

Learning Points

EAT-10 captures impact: Mrs. L’s EAT-10 score of 11 reflected moderate symptom burden despite her appearing “well” to the referrer. The questionnaire prompted appropriate priority referral.
Empirical management is appropriate for mild dysphagia with intact cough response and no red flags, provided clear safety-netting is in place.
Rehabilitation exercises improve outcomes: Neck-modified CTAR was appropriate given her cervical osteoarthritis — always tailor exercises to the individual.
Home education matters: Teaching the IDDSI Flow Test empowers patients to self-monitor compliance.

References

Belafsky PC, et al. (2008). Validity and reliability of the Eating Assessment Tool (EAT-10). Ann Otol Rhinol Laryngol, 117(12):919–24. PMID: 18349030
Trapl M, et al. (2007). Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen. Stroke, 38(11):2948–52. PMID: 17894481
Yoon WL, et al. (2014). Chin tuck against resistance (CTAR): a novel exercise for dysphagia rehabilitation. J Oral Rehabil, 41(1):23–9. DOI: 10.1111/joor.12108