Diagonistic report for Omoite William written on 10/11/2024.

Name: Omoite william

Gender: Male

Age :23 years

Adress: Soroti

Occupation: Peasant farmer and casual labourer.

NOK: Okalanyi kate

Presenting complaint

1. Inability to swallow saliva and coughing when trying to do so

2. Inability to bite
3. Progressive weight loss

History of presenting complaint

2months ago he was involved in a road trafffic accident. He sustained blunt laryngeal trauma,
left limb fractures and a dislocated jaw.He was rushed to soroti regional referral and an
emergency tracheostomy was done. An Indirect layngoscopy done revealed laceration in the
posterior pharyngeal wall, intact true vocal folds and false vocal folds. A pharyngeal repair
was done and he was discharged through orthopedic clinic to handle his fractures for 3
weeks. He was feeding through an NG tube until 1 week ago on oral trials of porridge when
he coughed the content through the tracheostomy tube. He was referred to Mulago hospital
for further management.

Family history

Married with two children. No history of smoking or taking alcohol.

Assessment.

An informal assessment was done to investigate his swallowing, voice and oral structures.

Swallowing assessment.

Performed 5 dryswallows with no contents. On palpation hyolaryngeal excursion was felt. On

oscultation with a stethoscope normal swallow sounds were heard.

1 swallow of saliva was made and he coughed and contents were observed through
tracheostomy.
4 swallows were made using the supraglittic swallow and he swallowed without signs of
aspiration.

Voice assessment

MPT: 17.6s with phonation breaks

S/Z ratio: was unable to make placements for the sounds.

Pitch. Was unable to sing up the pitch scale and had monopitched voice

Vocal profile

Reduced loudness, uncreased gravitas, normal resonance and no phonation breaks.

GRBAS score of 1 with an issue of grade.

Current mode of communucation was verbal attempts of phrases and gestures like pointing.

SLT impression; Oral pharyngeal phase dysphagia secondary to blunt laryngeal trauma

Plan

Enroll on dysphagia therapy.

Recommendations.

 To change NG tube scope guided due to his anatomical differences and the fact that it has
been available for 2 months
 Continue feeding via NG tube and oral trials made under supervision of the speech and
language therapist only because of high risk of aspiration
 To do an IDL or FOL to visualize pharyngeal and laryngeal anatomy.
 Do modified barium swallow to rule out tracheosophageal fistula.

Treatment plan

Longterm goals

Within 2 months William will make oral trials for 20% of his goal feeding using the
supraglottic swallow technique without clinician’s supervision and guidance.

Short term goals

Within 1 month William will swallow all his saliva using the supraglottic swallow technique
and will not spit in a bucket throughout the day without reminders from the clinician and
caretakers.
Within 2 weeks William will learn how to use the supraglottic swallow without cues and
guidance from the clinician over three consecutive sessions.

Interventions to be used

 Dietary modification due to inability to chew and bite

 Supraglottic swallow
 Breath hold
 Masako technique
 Chin tuck against resistance.

Generalization

Normal foods and saliva are to be used in therapy sessions

Family engagements

Relatives will attend all sessions and lead in some.

Progress report from 06/11/2024 to 08/11/2024.

Background info

Three sessions were carried out with William all aimed at perfecting the use of
supraglottic swallow on saliva and some oral trials. In all sessions goals were achieved
and use of the supraglottic swallow proved successful but he reported inability to
constantly use the swallow technique because of a globus sensation during continuous
swallows. During the course of the week 2 IDLs and a modified barium swallow were
done. The modified barium swallow was negative for tracheoesophageal fistula. The
IDL revealed normal pharyngeal walls and epiglotis. The vocal folds more to the right
than anterior to the oesophageal opening, alot of secretions some leaking into the
airway, false vocal folds visualised with only the right mobile on phonation, true vocal
folds not visualised, very narrow glottis opening and NG tube in situ. He was advised
for a review at the head and neck camp happening the following week. During the
week he made an oral trial without supervision of the therapist. which was
unsuccessful and he was reported by the clinicians at ward.

Comments

During therapy successful oral trials and dry swallows were made. He reported a
globus sensation on using the technique. An ENT was consulted about the sensation
and he said it could be due to the prolonged episode of not using his throat,
constriction after surgery and prolonged NG tube in situ. His spitting has not reduced.

Prognosis

He has a fair prognosis because of the successful oral trials during therapy however
his swallowing could be compromised due to his suspected anatomical deficits.

Plan of care.

He was discharged due to our end on clinical rotations but advised to seek speech and
language therapy services at the outpatient clinic from the clinician there. He was
referred to an oral maxillo facial surgeon, ENTs and head and neck surgeons for
further management.

Recommendations

Continue using the supraglottic swallow technique to swallow saliva so as to perfect

swallowing.

Restrict from oral trials without supervision by a speech and language therapist.

Progress report for Jesca Apio from 06/11/2024 to

08/11/2024 written on 10/11/2024.

Name:Apio Jessica
Gender:F
Age:46yrs
Contact:0760956194
Medical diagnosis: Acute laryngopharyngitis
Papular urticaria
Acute rhinitis
Neuro-myelitis
Residence:Kajjansi
Occupation:Nutritionist
Languages used:English and Atesot

Background information
Jesca is a review patient who has had sessions since 17/10/2024. On self admission
she had the following medical conditions; known ISS on HAART and neuromyelitis.
In her initial assessment she was diagnosed with Neurogenic dysphonia, flaccid
dysarthria in ISS after the following findings; good head and neck support with stiff
neck muscles, moderate jaw strength, but weak, uncoordinated tongue movements,
buccal tremors, uvula deviation to the right, hypernasality, pitch breaks, phonation
issues, limited breath support, and slow diadochokinesis. Therapy adressing breath
support, resonance, oral facial strengthening and reducing muscle tension was started.
Over the course of her sessions she reported improved breath support during speech
and daily life activities. She reported that her remaining concern was the hypernasality
in her speech.

Progress

Long term goals

1) Jessica will speak for 30 minutes without phonation breaks and pitch breaks and
reduced hyper-nasality in 4 months.

2) In 4 months, Jessica will make oral motor Movements with 80% accuracy without
resistance and 60% accuracy against resistance to improve on strength and function of
oral motor structures during speech and feeding Through resistance and movement
Exercises.

Short term goals

1) In 1 week, Jessica will execute diaphragmatic breathing exercises 10/10 times with
maximal visual, verbal and tactile cues from the clinician so as to increase breath
support.

2) In 3 weeks, facial and neck muscles will reduce tension by 60% with facial and
neck massages done by the clinician and maximal visual, verbal and tactile cues
provided to her caretakers as well.

3) Jessica will move her tongue in all directions (protrusion, retraction, elevation and
lateralization) against resistance from a tongue depressor or gloved finger with
maximal visual, verbal and tactile cues in 1 month.
4) Within 1 month, Jessica will increase her Maximum Phonation Time to 6s by
practicing phonation and breathing exercises in therapy sessions over 3 consecutive
therapy sessions.

5) In one month, Jessica makes lip movements with 60% accuracy and perform lip
strength tasks with 50% accuracy over 2 Consecutive therapy sessions.

6) Jessica will phonate with easy onset to reduce hard glottal attacks during reading
aloud of 5 sentence paragraphs with maximal visual, verbal and tactile cues in 5
weeks.

7) In 2 months, Jessica will make jaw movements with 70% scores without resistance
and 50% scores against resistance during therapy as assessed by the clinician over 3
consecutive therapy sessions.

8) Jessica will articulate phonemes /k/ and /g/ while naming objects with phonemes /k/
and /g/ in word initial, word medial and word final positions with 100% accuracy to
increase velopharyngeal closure hence reduction in hyper-nasality in 3 months.

Comments

Jesca executed diaphragmatic brearhing exrecises well without any verbal cues from
the therapist.

Jesca had reduced neck muscle tension

Jesca phonated vowels with easy onset during therapy sessions specifically /a/

Jesca perfroms oral motor exercises with an average of 80% scores for movement and
performs movements against moderate resistance from the clinician.

She makes tongue movemnets with support of the jaw and still cannot make tongue
trills

Makes lip trills for 2.5s without verbal cues from the clinician.

Jesca still has hypernasal speech characterised by nasal emissions on some sounds and
nasalising of some consonant sounds during continuous phonation of about five times

Her breath hold was 18.6s from 2.3s

MPT was 5.2s from 3.9s

S/Z ratio was 1.5 from 1.3 with S of 2.7s from 1.2s and Z of 1.82s from 0.9s

Summary

During the last two therapy sessions Jesca conversed for about 30 minutes without
pitch breaks, phonation breaks, loss of breath but with hypernasal speech. On
palpation over the last three sessions her neck tension had reduced and the floor of
mouth tension as well. She had shown great improvement from her initial assessment
results in the last session

Prognosis

Jesca has a good prognosis based on her improvement and dedication to therapy so
far. She will improve if she continues with regular sessions

Plan of care goals

Since some goals were achieved here are some new updated goals

Long term goals

 Jesca will engage in a conversations with no hypernasal speech within 4 months

 Keep the goal for oral motor exercises.

Short term goals

 Jesca will perform velar strengthening exercises with 60% accuracy over two
consecutive therapy sessions within 2weeks
 Maintain goals for MPT and S/Z ratio
 Jesca will perform tongue movement exercises without support of the jaw with
90% accuracy over three consecutive therapy sessions with moderate physical
cues from the clinician in two weeks
 Maintain other goals except for the jaw, diaphragmatic breathing and lip exercises.

Recommendations

Continue speech therapy activities at home and with the speech therapist in the out
patient clinic.

Interventions to be used
 Oral facial exercises.
 Behavioral speech therapy.
 Oral facial massage.