Management of dysphagia in a patient with closed head injury

This case report describes the evaluation and treatment of a closed head injured (CHI) patient with dysphagia and cognitive and language deficits. On October 27, 1985, the patient, a 35-year-old man, sustained multiple intracranial hemorrhages in a pedestrian-motor vehicle accident. Over a 4-month hospitalization in a rehabilitation setting, he progressed from nasogastric tube feeding to complete oral feeding with an unrestricted diet. When admitted to our inpatient rehabilitation unit 2 months after injury, the patient demonstrated confused, agitated, inappropriate behaviors and had a tracheostomy. He showed minimal neurologic impairment of his lips, tongue, face, jaw, velopharynx (i.e., palatopharyngeal isthmus), larynx, and respiratory motor mechanism. Three videofluoroscopic dysphagia studies were performed. Initial findings included pharyngeal paresis and laryngeal penetration of liquids. Safe swallowing was possible only by using compensatory strategies, such as decreasing bolus size and swallowing twice after each mouthful. Persisting cognitive and language deficits complicated the dysphagia treatment program. Behavior modification techniques, a structured environment, supervision, and family education were utilized to address the cognitive and language deficits contributing to dysphagia. The interactions of cognitive, language, and swallowing impairments are discussed. General considerations in the management of dysphagia in patients with closed head injuries are also addressed.