Dysphagia
https://doi.org/10.1007/s00455-020-10101-6
CLINICAL CONUNDRUM
Clinical Conundrum: Severe Oropharyngeal Dysphagia
Sonika Randev1 · Lara Goldstein1 · Kara Morgenstern1 · Anusha Lekshminarayanan1 · Eric L. Altschuler1
Received: 13 December 2019 / Accepted: 22 February 2020
© Springer Science+Business Media, LLC, part of Springer Nature 2020
History
A 62-year-old woman presented to an outside hospital with
complaint of three days of vertigo, not affected by posture,
associated with nausea and vomiting. The patient was admit-
ted to acute inpatient rehabilitation for balance difficulties
eight days later. On admission to acute rehabilitation, the
patient had complaints of dizziness. On examination, she
was found to have full strength and intact light touch in all
limbs but decreased pain and temperature in the left arm and
leg. Also, on bedside evaluation gurgling was apparent when
the patient attempted to swallow thin liquids. Speech therapy
assessment was also found similarly. The patient had arrived
on a puree diet with nectar thick liquids secondary to overt
signs/symptoms of aspiration including wet/gurgly vocal
quality post trials of all liquid consistencies along with poor
secretion management as seen through manual expectoration
of secretions. A modified barium swallow study (MBS 1)
revealed a severe oropharyngeal dysphagia with significant
regurgitation and reflux of puree boluses. Residue remained
within oropharynx. Penetration of nectar thickened liquids
was also observed during trials of nectar thickened liquids.
(Video 1). The patient’s MRI is shown in Fig. 1. What is
the diagnosis?
Sonika Randev, Lara Goldstein and Kara Morgenstern have
contributed equally to this work.
Electronic supplementary material  The online version of this
article (https​://doi.org/10.1007/s0045​5-020-10101​-6) contains
supplementary material, which is available to authorized users.
* Eric L. Altschuler
altschue@nychhc.org
1
Department of Physical Medicine and Rehabilitation,
Metropolitan Hospital, 1901 First Avenue, New York,
NY 10029, USA
Teaching and Clinical Points
MRI showed a small area of hyperintense signal within
the right dorsal lateral medulla on the diffusion-weighted
sequence and chronic microvascular ischemic disease. By a
week after admission, the vertigo had resolved. The patient
and her family were hesitant about having a percutaneous
endoscopic gastrostomy (PEG) tube placed, so a nasogastric
tube was inserted and used for nutrition and medications.
Dysphagia exercises were implemented daily including
jaw opening, effortful swallow, Mendelsohn maneuver [1]
for longer duration of pharyngeal contraction, and longer
bolus transit time. The patient performed Shaker exercises
to increase anterior to posterior diameter of UES opening
along with increased maximum anterior laryngeal excursion
[2, 3] and strengthening suprahyoid muscles [4]. Despite
slight improvement of the swallow mechanism, regurgita-
tion of the pureed bolus was still seen on the second MBS
(2 weeks later) along with aspiration of thin liquids (Video
2). The patient agreed to have a PEG placed. The patient
was discharged home with a regimen of dysphagia exercises
(mentioned above). An MBS (Video 3) seven weeks after the
initial onset of symptoms showed mild penetration across
all liquid trials and soft solid bolus regurgitation into oral
cavity requiring manual expectoration. However, during this
study, the patient tolerated puree consistency foods without
aspiration, penetration, regurgitation, or pooling. Patient was
placed on a puree consistency diet with supplemental thin
liquids (two 4 oz containers of thin liquid daily). Additional
liquids were provided via PEG tube. An MBS four weeks
later (Video 4) showed a mild oral and oropharyngeal dys-
phagia, but with no regurgitations, aspiration, penetration,
or pooling. The patient was upgraded to a regular diet with
thin liquids without further complication.
13
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Fig. 1  Axial cut of the patient’s T2 weighted MRI. See text for fur-
ther discussion
Discussion
In 1901, Adolf Wallenberg [4] described a now eponymous
clinical syndrome with pathologic anatomic localization to
the lateral medulla. Signs and symptoms include decreased
pain and temperature sensation on the ipsilateral face and
contralateral body, ipsilateral Horner’s syndrome, dyspha-
gia, dysarthria and dysphonia, nystagmus, vertigo, nausea
and vomiting [5]. Interestingly, nearly a century earlier
Alexander John Gaspard Marcet, MD [6] published a highly
detailed case study of Gaspard Vieusseux, in which he spec-
ulated that the peculiar sensations in Vieusseux’s head and
the derangement of equilibrium arose and related their sud-
den onset with vomiting, followed by a complete loss of
voice (without affecting articulation), considerable difficulty
in swallowing liquids, weakness of his left side, insensible
right side to being scratched or pricked, and finally hiccups
by the third day. This mirrors the oropharyngeal dysfunction
we saw in our patient and can be the most severe symptom
following a lateral medullary stroke. The most interesting
aspect of the dysphagia is how a unilateral brain lesion is
able to completely affect swallowing—a bilateral process. A
half century ago Doty et al. found [7] in electrophysiologic
studies in multiple animal species that a unilateral brain stem
lesion discoordinates swallowing muscles bilaterally. Our
case is good human analog of the findings of Doty et al.
13
S. Randev et al.: Clinical Conundrum
[7], and also well illustrates the still incompletely under-
stood recovery course [8]. We have a low threshold based
on clinical exam by physicians or speech therapy to check
an MBS, and the issue of whether an MBS should be part of
a standard work up after lateral medullary stroke is worthy
of further investigation.
Compliance with Ethical Standards 
Conflict of interest  The authors declare that they have no financial or
other conflicts.
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Sonika Randev  MD
Lara Goldstein  MS, CCC-SLP
Kara Morgenstern  MA, CCC-SLP
Anusha Lekshminarayanan  MD
Eric L. Altschuler  MD, PhD