Aspiration, swallowing dysfunction and chronic lung injury — branching viva

Opening

Examiner: This 3-year-old with cerebral palsy has recurrent right-lower-lobe pneumonia, long messy meals, a wet voice after feeds and constant drooling, and is losing weight. How do you approach her? ^[1]

Candidate: I would frame this as likely chronic aspiration in a high-risk child, and my first task is to work out whether she is aspirating, by which route, and how injured her lung is. The recurrent pneumonia anchored to one dependent region, the wet voice and the drooling all point to aspiration, probably by more than one route. My plan is a multidisciplinary feeding-and-airway assessment, and I would not simply treat each pneumonia in isolation. ^{[1] [6]}

Branch 1 — confirming and characterising

Examiner: Her carer says she does not cough on feeds. Does that reassure you? ^[1]

Candidate: No. In cerebral palsy laryngeal sensation is often blunted, so aspiration can be silent with no cough at all. The absence of coughing does not exclude aspiration, and her chronic chest disease is itself the clue. I would arrange a clinical feeding assessment and, because the bedside evaluation can miss silent aspiration, add an instrumental study. ^{[1] [3]}

Examiner (probe): Which instrumental study, and what does it add? ^[2]

Candidate: A videofluoroscopic swallow study or fibreoptic endoscopic evaluation of swallowing. The videofluoroscopic study watches her swallow different textures under fluoroscopy and shows aspiration and its timing, while endoscopy views the pharynx and larynx directly. Both reveal silent aspiration the bedside assessment misses and tell me which textures are unsafe, so I can modify feeding rather than guess. ^{[2] [3]}