Bone Spurs & Bolus Flow: Cervical Osteophytes and Dysphagia

Speaker0:
[0:15] Hi, everyone. I'm Emily.

Speaker1:
[0:17] And this is Eva.

Speaker0:
[0:18] And you're listening to Speech Talk.

Speaker1:
[0:21] We're your research book club so you can do evidence-based practice in practice.

Speaker0:
[0:25] Let's start talking.

Speaker1:
[0:27] Okay, so any fun notes from this week, Emily?

Speaker0:
[0:30] I visited my PRN for the first time in a long time. And I learned that the blue dye test is still a thing. I didn't know that that was a thing anymore. And I went to my eval of the day. He was a trach and eating regular food. He was like, oh, yeah, they gave me all of that food with the blue dye in it. And I was like, oh, great. You had a fees. And I started explaining that. And he's like, no, no, no. The blue dye. It's like, what? Called the other facility. And they're like, yeah, blue dye test. No dye came through his trach. It's like, oh, OK. Okay, so ordering a feast. Thank you very much.

Speaker1:
[1:17] And that sounds like another podcast episode. Feature episode topic.

Speaker0:
[1:22] No, we will definitely be going over the pros and cons with a blue dye test. Holy cow.

Speaker1:
[1:29] I don't know if this is like a fun story. I don't know. I think overall our fun stories are usually like, oh, something went wrong.

Speaker0:
[1:37] Yeah, I think we have like a bad fun-o-meter. Like we just don't know what fun is anymore. Like, recording these podcasts are fun, and that's, I can't say my highlight of the week is recording a podcast.

Speaker1:
[1:51] Yeah, because not similarly, like, incorrect treatment performed, but yeah, mine was similarly, like, oh, I got a dysphagia patient. What does their documentation say? Nothing interesting on oral eval. Unremarkable. I look in this woman's mouth. The tissue is so swollen. Like you can't even really visualize the oropharynx. Like it's not dark. It just looks like swollen pink tissue. When she talks, you can literally see air bubbling up through mucus in the back of her throat. And I was like, who wrote unremarkable on her chart? Like what is wrong with you? Anyways, sorry to call you out if you wrote those documents but my god uh anyways we ended up sending her out to the hospital like immediately following my eval i like brought the doctor and he was like oh yeah this is bad she hasn't been back uh hope you're doing well if you're out there listening hope hope you're feeling better in the hospital and they're gonna come back to us soon oh

Speaker0:
[3:04] My gosh i don't would you love it though when the doctor is like yes this is bad i agree let's let's work together i feel to make this.

Speaker1:
[3:13] Not our fault oh wait though on that note the resident who was shadowing with him uh had me read the swallow study that apparently they only had access to it was a bad swallow study and I was like, why didn't anybody send me this? But story complete for another time. And then I was like, oh yeah, this is what, her MBS looks like. These are the concerns. And he turned to me and he goes, could you maybe explain it in English for those of us who don't understand? And I was like, I get to explain something to a doctor. So excited.

Speaker0:
[3:53] Oh my God, your doctor. I thought you were saying the patient didn't understand what you were saying. And I'm like, yes, typical. But the doctor was like, can you explain that to me? That's so cool.

Speaker1:
[4:03] Yeah. I was like, what's up? Let me tell you. Actually, this patient, this transitions nicely into our topic for the week. This patient has anterior osteophytes. So let's talk about what we're discussing today. We're getting into osteophytes and specifically cervical osteophytes. So let's jump into it and I'll circle back to this patient's story later. Yeah, I want to talk about osteophytes because a while ago I had a patient who came in, had the only thing that was on his chart was cervical osteophytes. And I said, what does that do to a swallow? And it turns out terrible things is what I learned on his e-mail. It was just gurgly sounding, profuse coughing with eating. We had them on purees and thickens. And I just remember going, well, like, what do I do? there's like a bone in his throat like what am i

Speaker0:
[5:04] Yeah let's let's so what is a cervical osteophyte it is a bony spur or growth that is most likely occurring in the cervical spine cervical osteophytes cervical spine bony growth in the spine where your throat is, So these things are happening because or usually because of a degenerative condition such as osteoarthritis, spondylosis, and spinal stenosis.

Speaker1:
[5:36] Oh, it wasn't spondylitis? Spondylosis? That's a word? Dang.

Speaker0:
[5:40] It might not be. S-P-O-N-D-Y-L-O-S-I-S.

Speaker1:
[5:45] That's what that sounds like.

Speaker0:
[5:47] Spondylosis. It's a fun condition that caused you to not be able to swallow. These cervical osteophytes or these growths are thought to be your body's attempt to repair itself. So they can form after these degenerative conditions or after injuries or trauma like a car accident. They can form over time with age and bad posture. So I will get it.

Speaker1:
[6:15] I also like the idea of just like age being that degenerative change that comes for us all. But, yeah, going back to this idea that, like, there's just these bony growths that are hanging out in the pharynx, predominantly, if we're looking at the cervical region. And I was pretty confused as to what to do about that, because general philosophy is you can't change bones, right?

Speaker0:
[6:42] Yeah.

Speaker1:
[6:43] So I started out with looking at a case study, but it was geared towards someone who's much older than my patient. So I read another case study and some other random stuff from Melbourne Swallow Analysis Center, you know, way down under. And then there was a little Science Direct and then something from the American Journal of Medicine, of Science or Medical Science, whatever it is. And finally, after all of this, I kind of feel that I've pieced together a good idea of how we should be managing, at least from the SLP side, osteophytes. Cervical osteophytes. Really went down the research rabbit hole with this one.

Speaker0:
[7:22] Yeah, I hate when that happens.

Speaker1:
[7:24] I know. You have like 15 links open on your computer and you're like, where am I? What day is it?

Speaker0:
[7:30] You're in one research article and they're like, talking about so-and-so in 2019. And you're like, ooh, what did they say?

Speaker1:
[7:38] What did they say in 2019? I got to know. So let's jump into what we would be seeing with our patient symptoms. Turns out they've got osteophytes. What are we seeing? So it turns out it's a lot of just regular dysphagia stuff. There could be globus sensation, discomfort with swallowing, coughing or choking while swallowing, wet, gurgly sounding voice, pretty much your regular run-of-the-mill dysphagia. So unfortunately, in some cases, there are no clear indicators, except that they may steadily be worsening over time as that osteophyte either protrudes or gets larger.

Speaker0:
[8:13] In other cases, besides dysphagia, the anterior cervical osteophyte might result in a dysphonia, so like your voice is hoarse, strained, etc., or a dyspnea. How do you say that?

Speaker1:
[8:29] I think dyspnea. I don't know.

Speaker0:
[8:32] Dyspnea. You know, fun story. My niece, Charlie, once I was reading her a bedtime story, and the word pterodactyl was in there.

Speaker1:
[8:43] You said pterodactyl?

Speaker0:
[8:45] I said, and she, at like four, she was like, Auntie, it's pterodactyl. And I said, thank you, Charlie. Continue to read the story with my head down. And that's why I read research

Speaker0:
[8:59] with big long words. To practice.

Speaker1:
[9:02] It's just to practice for bedtime stories. Yeah, so dyspnea. It's not fair to put an S, a P, and an N next together in English. We don't typically do that. It's just like shortness of breath. But the issue is we still don't have x-ray vision as clinicians, do we, Emily?

Speaker0:
[9:20] No, we don't. Sure don't. Maybe one day.

Speaker1:
[9:24] Goals.

Speaker0:
[9:24] So we have to get imaging done, right? That we can use an MBS, which is going to show those bony growths, or a FEES, which can show the protrusions or the limited amount of space that is in the pharynx or your throat cavity.

Speaker1:
[9:42] Yeah. And when you do see it on a fees, it's really protruded. Like it's pretty hard to miss. It fits at the stage where it's impairing somebody's swallow. From my experience and from some of the research I read, the imaging on these osteophytes, it's like a golf ball. There's like a big old solid chunk of throat wall poking in. Yeah. I know, that was a really technical and professional description. But then once it's confirmed by radiology and we can get some imaging done, there's essentially two treatment options. Emily, tell us what our two methods are.

Speaker0:
[10:23] So first, and probably most commonly used, especially in our situation where we have very geriatric patients who are not very gerries, Not very suitable for surgeries, but we have that conservative treatment. So a textural management, like downgrades, swallow strategies, anti-inflammatories, anti-reflux, and muscle reluctance. Surprised by those last ones.

Speaker1:
[10:57] I was too. So apparently the anti-reflux is just to help manage actual GERD. Like you don't want people refluxing if they're having trouble with swallowing. So I think it's an overall dysphagia management strategy there. But the anti-inflammatories apparently can help manage some of the swollenness in the pharyngeal cavity. The muscle relaxants, I don't know, they didn't really explain it. They were like, and he was treated with also muscle relaxants. I was like, all right, cool. He's I'm at a good time. It's like popping muscle relaxants, hanging on the couch, eating puree ice cream.

Speaker0:
[11:32] Well, when you say like that, the anti-inflammatories, like, yeah, if your body is reacting to an osteoarthritis or something like that and creating these spurns, then maybe the, anti-inflammatories will slow that reactive process down too. So that one thing. I just had to hear you talk about something, Eva, and it helped.

Speaker1:
[11:54] That's why we meet. That's why we meet, is to talk about stuff. And then option two, slice and dice them. Does surgery that situation? I think the term in this case is osteophytectomy, which is the most letters on the Scrabble board.

Speaker0:
[12:11] You win.

Speaker1:
[12:13] Yeah. Yeah, which so basically if the conservative management has failed, we want to do, we don't necessarily want to do a surgical intervention, but it can now be brought up for discussion. And the long term outcomes, according to the research, are pretty good. The main issue is that when you're cutting into the cervical spine, there's like a lot of other important stuff there, like nerves and your vocal folds and, you know. Nerves.

Speaker0:
[12:48] Yeah.

Speaker1:
[12:49] Which can lead to like paralysis in certain regions or lack of sensation.

Speaker0:
[12:54] Right. And I think a lot of times when they have these surgery, they come through anteriorly. So they're coming through the front of the neck, passing all those things to mess with those bony processes on that anterior side. So yeah, even more problems that can be had that way.

Speaker1:
[13:14] Yeah. All I have to say, not to be embarked upon lightly.

Speaker0:
[13:20] Yeah, I can't imagine any of our patients are getting surgery done.

Speaker1:
[13:25] No.

Speaker0:
[13:26] They'd sooner be pegged than have that surgery.

Speaker1:
[13:30] I don't think you can say that on air, Emily.

Speaker0:
[13:36] Not like that.

Speaker1:
[13:41] I guess that's probably our first truly inappropriate joke. But let's get into two of the case studies that we looked at. These were for our very Jerry patients. I'm keeping that. I want it on a shirt. Very Jerry. You heard it here first, folks. And they use the conservative treatment options because of their age. There was like, surgery is not really appropriate for someone who's 84. And they had good outcomes insofar as the dysphagia was managed via textural modifications and some of those drugs, either the anti-inflammatory, muscle relaxants, or the anti-reflux. But it wasn't gone completely. We're just trying to cope with signs and symptoms. We're not dealing with the underlying problem. So they still had difficulties with eating and swallowing, but they weren't aspirating as much. Yeah, so their dysphagia signs and symptoms were managed, but we're not fixing the underlying problem. I will say that the process recommended regular follow-ups for these patients because we're not treating the underlying problem. We want to see the progression. Are the osteophytes continuing to protrude? Do the textures need to be further downgraded? Are the swallow strategies still effective? So that was also a component of their care was regular follow-ups with fees.

Speaker0:
[15:10] So the surgical intervention article, there was two patients who underwent anterior cervical osteophytectomies due to severe dysphagia. A long-term follow-up showed both patients with improvements in swallowing and associated pain. So yeah, surgery can have a good long-term outcome. I think I read in one of the studies the patient was 61. So not terribly young, but...

Speaker1:
[15:36] Not a young grad, but, you know, still with time left on the clock, so to speak. In another paper we read, it was a review of osteophytectomies in ScienceDirect. They showed that patients improved their functional outcome swallowing scale scores. Say that 10 times fast. Which basically is, if you don't do the FOSS, if you have a higher score, you have a bad swallow. So they had improved or lower scores On the other hand, there was a 27% complication rate. So again, very tricky region to be operating on. They found that having a high FOS score or a bad preoperative swallow was a prognostic indicator of poor postoperative functional swallow outcomes. What does that mean? You're going to have a bad swallow afterwards. So again, when we're advising our patients on, you know, is this potentially appropriate for you, just reminding them that, hey, a surgery will improve the situation, but there's still a decent chance if you got a bad swallow before, you're going to have a bad swallow after.

Speaker0:
[16:42] That's that New York accent coming back up.

Speaker1:
[16:45] I keep sleeping and slipping into.

Speaker0:
[16:50] Yeah, and I think that kind of brings us to or back to our episode before about prehab. You know, maybe doing some exercises before those osteophytes. I mean, maybe they're getting in the way. They're messing up those swallow muscles in there. So doing some pre-surgery exercises.

Speaker1:
[17:13] We need to start doing like a buzzer for like research opportunity. Like, you know, because I feel that in these conversations, we start coming up with, well, hey, that sounds like a good opportunity for prehab. What is the impact of prehab on anterior osteophytectomies? Like, oh, you PhDs, get out there. You go do that research. Publish it. Call us. We'll review it.

Speaker0:
[17:39] And we'll have you on. Come talk to us. Yeah.

Speaker1:
[17:42] Come talk to us. So yeah, and an important surgical consideration is that there's a potential for spinal instability, particularly if the osteophytectomy is going to be performed at three or more spinal segments. So again, if you're taking stuff out, might make stuff more loose afterwards, aka spinal instability. And I know that was the really technical way to describe that. Could get loose afterwards. So yeah, even if you manage to not cut anything important during the surgery, there's still the potential that you destabilize some of the spine afterwards. So just adding a little more risk to the equation because that's fun.

Speaker0:
[18:27] Yeah, and likely after all this surgery, we're going to end up on a modified diet for a while anyways.

Speaker1:
[18:34] For real.

Speaker1:
[18:37] So a quick summary of everything we just looked at. Osteophytes, they can present like regular dysphagia, but they might get worse steadily over time and present with dysphonia or dyspnea. It needs to be confirmed through imaging. Once it's confirmed, you can either go the conservative treatment approach, or if that's not effective and they're eligible for surgery, then maybe we go for a surgical consult. And make sure your patients and their families are well-informed about potential risks and trade-offs. Side note, not really on this particular subject, but on the education, I had a guy come in, real bad dementia, and the doctor okayed enteral feeding. I'm like, were they counseled on this decision before you're undergoing surgeries or doing anything with people who are A, particularly old, or B, have dementia? There are contraindications. So please take the time to make sure folks are well-informed. Thank you.

Speaker0:
[19:40] Yeah, I think this topic really goes to show how important those instrumentals are and how important it is for us to advocate and educate our facilities. Like I get it. Asking for an instrumental sucks because facilities don't want to pay for that overhead and they don't like to improve them unless they're absolutely necessary. So going in with this and having an instrumental done for someone who is older, reminding your facility like they are a choking risk because there's literally something in their throat. Like we can't see it until we see it. We don't have x-ray vision. So we have to know what we're doing. So if they're coughing or they're throat clearing and they're always wet and gurgly, like demand those swallow studies. Say, I've been seeing this person for two weeks. I don't see any improvement. I need more to be able to continue treating them properly. Because you have to.

Speaker1:
[20:45] Yeah, we don't know what's there. I tell my patients that all the time. I go, I don't have x-ray vision, so I'm recommending the swallow. And they usually laugh. Not swallow. Swallow study. But yeah, it's very real.

Speaker0:
[20:59] Yeah, I had one. I mean, I've had several patients that, like, there's just, like, cervical osteophytes mentioned in their chart. And I'll check in on them. Like, oh, no, you know, nothing's going on. Da-da-da-da-da. Fast forward six months. Now they're choking.

Speaker1:
[21:16] Yeah. Yeah. And it's that progression. And that's why you shouldn't feel bad about checking in on your med bees. If somebody has a progressive condition, it's going to change over time. So if someone's like, oh, you're just pulling up med bees because you're trying to like milk the system. It's like, no, actually, there are people with progressive degenerative conditions. And we need to make sure that they're still safe. It's valid. Yeah.

Speaker0:
[21:42] Yeah. And something like this would warrant like two, like, you know,

Speaker0:
[21:47] I wouldn't just check in on them, especially if they're with us long term. You know, they have a dementia. You ask them how things are going. They're like, oh, it's fine. I haven't had a problem. Like, okay, do you mind if I sit with you for a few meals just to see how things are going? And pay attention. Are they coughing throughout their meal? Are they having those throat clears? When you're talking to them at their meal, do they sound wet and gurgly? Are they swallowing a few times? If you're seeing things that look different than your last meal evaluations, then, you know, maybe it's time for another instrumental.

Speaker1:
[22:22] Yeah, exactly. But circling back to the patient who kind of got me interested in this from the get-go, he, to your point about cognition, we're always bringing up cognition and dysphagia. He had a former substance abuse diagnosis, and his kind of bodily awareness was really bad. And so we did textural and swallow strategy management with him. We got him from puree up to regular foods again. And so I wanted to show him the progress that he'd made when he first came in. I mean, it was just such a terrible, wet-sounding, coughing, everything swallow. And part of what was happening was that the epiglottis wasn't fully inverting because of that osteophyte protruding into the pharynx. And so his vocal folds weren't protected. And we do all this work, get him to do these strategies. He's finally eating regular foods again. We go through the eat 10. He's like, yeah, I don't think I had a problem with any of those. I was like, oh, dang it. All of this work, all of this very careful monitoring of your meals. And you're just like, oh, my poor bodily awareness, my reduced sensation means I haven't brought us to any of the changes we've done together. Oh, wow.

Speaker0:
[23:48] Terrible. And you're like, remember, remember that thing that we did? Remember that thing we did 200 times because you told me you were choking? Do you remember that? Yeah. Was I the only one here?

Speaker1:
[24:02] I would be like, all right, how's your super subglottic swallow? He's like, I don't,

Speaker0:
[24:07] I don't know What's that? What's that?

Speaker1:
[24:09] And I was like, it's on the daily chart that I printed out for you For all of your meals For all the exercises you're supposed to do before them Slash with them Oh well Anyways, he left eating fine. Good for him.

Speaker0:
[24:25] It doesn't matter the process and the pain.

Speaker1:
[24:29] Yeah. Well, and my second patient with the osteophytes, he is a recent admit. He's got cancer. It's not head and neck, but he generally has a lot of growths in other parts of his body besides the pharyngeal osteophyte, even though he is on that younger side, like one of the patients in the research who's only in his 60s, he could be eligible, except that long-term, he's already got a terminal diagnosis. So unfortunately, we're still just on that degenerative conservative management train. And although they didn't bring this up, obviously our folks who are on hospice, we're taking the conservative treatment approach. If somebody has a DNR on their chart and you find out they have osteophytes, you know, educating them, being like, look, I know you have a don't resuscitate. If you're more on the kind of let nature take its course vibe of your plan of care goals, you know, maybe we don't want to go the surgery route in our recommendations.

Speaker0:
[25:39] Yeah, I can count on my hand how many times I've seen long-term patients go for surgeries, even in the neck area at all. At the point that they're living at a nursing home, Their body is like too weak, too far gone to really handle those things.

Speaker1:
[26:03] Yeah, that's tough. Surgeries are invasive. The healing time is tough. It's a rough situation.

Speaker0:
[26:09] And following recommendations is hard, too. So if like you were talking about, removing parts of three or more osteophytes causes weakness, Like you're going to have to be diligent about wearing a C-collar.

Speaker1:
[26:28] Oh, man. Getting people to wear C-collars appropriately. That's a whole other situation. How much time do you have to talk? Oh, man. Particularly if they have poor memory. Oh, man. Oh, it's.

Speaker0:
[26:45] No. And they're like pulling at them. Forget about cleanliness. Oh, Lord.

Speaker1:
[26:51] Oh, yeah, dude. Dude, the amount of soup stains and just like chunks of food I've seen on seat collars.

Speaker0:
[26:58] Nasty. And the aides are like, can we wash these? I was like, who didn't order two?

Speaker1:
[27:05] Why can't we swap them out? For reals, for reals.

Speaker0:
[27:10] All right.

Speaker1:
[27:11] Meeting adjourned. Now go sneak some evidence-based practice into your team meetings.

Speaker0:
[27:16] Thanks, guys.

Speaker1:
[27:18] Have a good one.

Speaker0:
[27:20] You've been listening to Speech Talk.

Speaker1:
[27:22] Thank you, everyone, for coming to listen to our research book club. Until next time, keep learning and leading with research.

Speaker0:
[27:28] If you like this episode and you want to give us some love, please rate us on your favorite podcasting app. Leave a review and tell the world, because as podcasters, our love language is in positive affirmations.

Speaker1:
[27:40] If you have a research topic you want us to cover, or you have episode comments, clinical experience you want to share, or just want to send us some love letters, send us an email at hello at speech talk pod.com.

Speaker0:
[27:53] If you want even more speech talk content, check out our website at speech talk pod.com where you can find all of our resources we made for you copies of articles covered and Eva's blog, following these topics and more.

Speaker1:
[28:06] We're your hosts, Eva Johnson and Emily Brady.

Speaker0:
[28:09] Our editor and engineer is Andrew Sims.

Speaker1:
[28:12] Our music is by Omar Benzvi.

Speaker0:
[28:14] Our executive producers are Aaron Corney, Rob Goldman, and Shanti Brooke.

Speaker1:
[28:19] To learn about SpeechTalk's program disclaimer and ethics policy, verification and licensing terms, and HIPAA release terms, you can go to SpeechTalkPod.com slash disclaimers.

Speaker0:
[28:31] SpeechTalk is a proud member of the Human Content Podcast Network.

Speaker1:
[28:47] Bye.