Objective Evaluations of Swallowing (for people who didn’t know that was a thing)

Today I let people jam a foot of tubing through my nasal passages and down my throat, then yank it out.  In and out, in and out.  16 times.  And I did it to each of them too.  Fun, huh?  But I’ll get back to that.

First, a little knowledge…

Difficulty swallowing (or “dysphagia” as it is more technically known) is an incredibly common occurrence in people who have had strokes, brain injuries, Parkinson’s disease, certain cancers, cervical spinal surgeries, and many other conditions.  Even normal aging can take a toll on swallowing.  Dysphagia is a significant concern because it impacts nutrition, quality of life, and very notably it’s a huge risk factor for aspiration pneumonia, which is when food or drink go down the wrong way (as in, into the lungs) and cause an infection.  This study from 2002 says that mortality from aspiration pneumonia has been reported to be as high as 70%, so it’s kind of a big deal.

There are a lot of low-tech ways that SLPs can judge how safely someone is swallowing, but the best practice is to have an objective examination.  Two different procedures fit the bill:  FEES (Fiberoptic Endoscopic Evaluation of Swallowing) and VFSS (Videofluoroscopy Swallowing Studies).

In short, FEES involves threading a scope through the (surprisingly complex) nasal passages and pointing the camera down the throat while you give your patient different consistencies to eat and drink.  You get to directly visualize the structures and see what happens before and after the swallow.  Here’s a picture of what it looks like down there.

say "ah"!

You might even want to take a look at this video of a FEES.  (If you’re easily skeeved, maybe you should skip this one.)

How cool, right??  A quick narrative of what you’re seeing: The popcorn falls down the base of the tongue behind the epiglottis into what’s called the vallecula (at the bottom of the screen).  Then the knobby things (the arytenoids) come together and pull the vocal cords together (in the middle of the screen) while the epiglottis flips over and makes the screen go white.  In that split second, the food has sneaked down a hidden sphincter at the top of the screen (the upper esophageal sphincter) to make its way toward the stomach.

Look at how complicated swallowing is.  And that’s only one small part of it!

Now the other method: The Videofluoroscopic Swallowing Study (or Modified Barium Swallowing Study- same thing).  VFSS is my usual method of objective swallow assessment.  It observes the same exact event (swallowing) and most of the same structures but from a perspective completely different from FEES.  Again patients are given different consistencies to eat and drink, but this time all food is mixed with barium so that an xray can capture a video of the patient swallowing each item (usually from the lateral view).  Compared to a FEES you see more of the mouth and the esophagus but it lacks the detail of a direct, color image.  Take a look at this:

That was a video of someone’s VFSS in both lateral and anterior views (I rarely do an anterior view).  This time we see someone’s profile, which is definitely easier to place than that vaguely vaginal structure from the last video.  But a lot of the same structures are there.  For example, that big pringle-like structure from the FEES (the epiglottis) is now a tiny curved protrusion just south of the jaw (see it?).  The 2 pyriform sinuses (see image above) are morphed into one general area near the back of the throat.

Both evaluations have their merits and one is not considered the gold standard over the other.  The advantages and disadvantages of each is a serious topic, but my goal here is not to write a clinical essay.  This is simply an introduction for people who’ve probably never thought that much about their swallowing.  And I hope you never have to!

Okay, so back to that giant invasion of personal space I mentioned earlier.  No, I’m not a masochist.  By this point you probably have guessed that I attended a course on Fiberoptic Endoscopic Evaluation of Swallowing over the weekend.  And despite the slight irritation I still feel on my posterior pharyngeal wall, it was pretty interesting.  I will leave you with some pictures of me being scoped by one of the doctors I work with.  (I guess nothing encourages team-building like sticking tubes in each other…)

A little blurry but you can tell how long that baby is

A little blurry but you can tell how long that baby is

Don't let that smile fool you

Don’t let that smile fool you…

You can kind of make out my larynx on the monitor

You can kind of make out my larynx on the monitor

If you have any questions about swallowing or the role of an SLP, please ask!  And if you’re an SLP who somehow stumbled onto here, I’d love to hear how you use these evaluations in your practice.  Happy swallowing!


So you agree?

I found a new Zumba class Saturday morning only 10 minutes away from my house.  I’d been itching to find one ever since I ditched my expensive (but inclusive) gym membership in favor of the gloriously cheap Planet Fitness (which offers 0 classes).  Luckily this new class is high-energy, fun, and even affordable.  Woohoo!

At the end of the class, the instructor came over and kindly complimented my ability to follow along.  (Look Mom, 12 years of dance lessons paid off!)  You’d think “thank you” would be the polite reply, but instead I started spewing out all the excuses (“I’ve taken Zumba before” “You gave great cues” etc.), as if the compliment were an accusation.

It stuck with me on the drive home.  A simple “thank you” would have been perfectly acceptable.  And in retrospect, so much suaver.  But in the moment it felt brash to accept the compliment.  As if acknowledging prowess would be arrogant and alienating.  Even Lindsay Lohan knows that’s dumb.

Okay, so Lindsay and I know that’s a crazy reaction to have, and hopefully not a common one.  But maybe owning a compliment really can get you scorned.

Check out this BuzzFeed article about woman who started agreeing with the guys who complimented her via social media.  They’d say “your pretty” (I assume they use the wrong “you’re”), she’d say “yes” or “I know, thank you”.  Kind of a socially atypical response, true.  But the responses from some of the guys were ridiculous.  Many of them retracted their compliments while others resorted to really nasty name calling.  Acknowledging your strengths (even the physical ones) does not make you a rude person, a bitch, or a “feminist cunt”. The originator of this experiment asserts that “for many men, beauty, coolness, [and] desirability are gifts they alone can bestow upon women. They get baffled, even aggressive when you show you’ve known you possess those things all along.”

The”humble-act” does seem to be a gender issue.  My guess is that woman are more likely to deflect praise and that it’s due to experiencing an adverse reaction to confidence.  It’s actually a pretty dumb cycle.  Person A lacks the confidence to demonstrate confidence because she knows Person B lacks the confidence to accept Person A’s confidence.  Follow?

Anyway, the good news is that this seems to be more of a perceived barrier than an actual one, especially for those of us new to adulthood.  I for one hope to shake the compliment-dodge that once seemed like the right way to handle praise.  If you want to give me props, why should I argue?

And by the way, I did rock that Zumba class.

An Anecdote from Love

Love is when, despite having to work Saturday and Sunday, you decide to go to a party two states away Saturday night and when you get home, exhausted and dreading the imminent 6:30 wake up, you realize you still have to make a lunch for tomorrow, but then immediately your equally tired husband who spent 3 hours of his night driving insists that he will make your lunch while you get ready for bed, so you decide you’ll have some water before bed but you somehow bobble the glass (that actually has finger holds for improved glass gripping) and it crashes all over the kitchen counter and floor into a million pieces that your husband again insists on cleaning, vacuum and all, while you get ready for bed, and then to top it off when you open your lunch Sunday afternoon, after all that, you find your husband still felt compelled to leave you a little note to help you through the day.


Balashi’s an Aruban beer

That’s love.

Now I’m off to Aruba for a few days!  If you’re reading this, I wish you a happy and fulfilling new year.  2015’s gonna be a good one.  Or painfully cataclysmic.  Who knows.

I Totally Can May Should Will

Happy 2 year anniversary of my first WordPress blog post!  Two years ago to the day I got the writing bug and unveiled the Post-Apocalyptic Optimistic Blog.  By mid-March that bug had been squashed.  Then, come early January the following year, the urge to spew my thoughts on a public forum suddenly resurfaced and Can May Should Will was born.

So what is it about the onset of winter that incites my desire to blog?  After all, I’m working on 3 years in a row of wintry blog reincarnation.

It’s definitely not that December is boring, because it’s not.  I’m working hard, starting a side business, spending more time with family and friends, having fun with my husband in our new home.  And yet there’s a sense of stagnation that accompanies bald trees and gray skies.  I guess early-onset darkness and increased TV time start to take a toll on creativity.

Then there are the holidays.  They make us want to feel connected and purposeful.  Plus seeing friends and family reminds us of how rarely we see friends and family, and that we should probably keep in touch better.

Last time around, I wrote a post called “Why Blog?“, which really brings this all home.  The list of 10 reasons to blog kind of reads like 10 ways to beat the winter blahs.  So let’s give this another shot.  Even if my blogging succumbs to the first no-jacket day of spring, I’m excited to start back up.  And who knows?  Maybe it’ll stick this time.

I Am Twitterpated!

I am twitterpated!!  For those of you unfamiliar with this term, it has nothing to do with my character count (…140 of anything would not be adequate to express twitterpation!).  It has to do with buds on trees, interlocking hands, a hop in your step, and good things on the horizon.

The word “twitterpated” was popularized in the 1942 Disney classic Bambi when Friend Owl explains the dizzying springtime emotion that overtakes nearly every young animal.  Take a look:

Sure, it seems that the original meaning described yearly mating rituals or, at best, romantic swooning.  But in my lexicon (and actually in the Oxford English Dictionary), the meaning of “twitterpated” has expanded to any feeling of buzzing excitement and anticipation.

This is probably one of my favorite neologisms.  It is so intuitive.  The twitter- part is practically onomatopoetic.  It almost even has a kinesthetic component, requiring lingual movements that mimic an excited musical trill.  The –pated part draws on connotations of anticipated or syncopated (hopefully not constipated!), so this word naturally evokes an energetic anticipation.  Couldn’t have coined a better term myself!

So now that we all know about twitterpation (twitterpate, twitterpater, twitterpatable, twitterpating… derivations are fun!), we can talk about why I am so twitterpated right now.  Well for one thing, this behemoth winter appears to finally be receding.  My car dashboard reads 40 in the morning instead of 20, and I’m pretty sure I wore sandals at least once this month.  I have not dug my car out in at least a few weeks.  Things are looking up.  Of course, being the newlywed I am, I do not need the excuse of spring to be all loveydoveysmooshymushyface with my husband.  But the thought of being able to go on hikes and lay by pools is pretty fantastic.

But wait, there’s more!  The even more twitterpating event in my life right now is our recent real estate purchase.  Yes, you read right- Ari and I bought a townhouse!  It’s pretty great in its own right- 3 floors, 2 bedrooms, 3.5 baths, a deck with a view, a pool in the community, a big soaking tub (ahhhhhh).  But the true cause of my twitterpation is that the rest of my life can start this June.

Don’t get me wrong- things are pretty damn great in my world right now.  But for almost a year, Ari and I have been picturing ourselves somewhere else.  Our apartment (which I affectionately refer to as “our shoebox”), no longer feels like a place where we can grow.  Easy now, I’m not talking about “growing our family”.  I’m talking about growing ourselves as individuals.  Despite the beautiful brick wall I am currently sitting next to and the quirky, soulful town right outside the door, I feel stifled here.  I’ve always seen our immediate future elsewhere, and therefore feel constrained by the temporary nature of my home.  Seems a little counter intuitive when I put it like that.  But despite wisdom telling me to live in the moment, the fact of the matter is that, for at least the last few months, I have been simply waiting.

Finally I can see what I’ve been waiting for and I am downright twitterpated about starting it.  This new home not only provides a beautiful and adequately-sized space to pursue my interests; it also provides a home base from which I can start long-term endeavors.  There are so many thoughts that have been flying through my head… the best I could do would be to list them:

  • Decorate my home beautifully
  • Play the piano or even take lessons again
  • Take on a few private patients
  • Join a yoga studio or get into the routine of a home practice
  • Join a new gym
  • Make new friends
  • Spend more time with my old friends
  • Start a garden
  • Write a book (one day!)
  • Get involved in the community
  • Explore state parks in the area
  • Host more get-togethers
  • Cook amazing meals and EAT THEM AT A TABLE  (no kitchen table in our shoebox)

Perhaps I am being over-optimistic.  In truth, I will be the same person, with the same amount of free time (maybe less), with less money, and with more responsibilities.  And on top of that, many of these ambitions I could theoretically implement right now.  But I suppose this is my New Year’s Day- the time when new horizons looks so shiny and attainable, and I’m okay with that naivety right now.  The spark that blinds me also propels me.  The possibilities of spring have me all twitterpated… and I like it.


My 10 Favorite Vegetarian Protein Sources

When I was 12 I used to say, “I’m not a vegetarian, I just don’t eat meat.”  I’ve never been a big fan of labels, but 15 years later, I think it’s safe to call myself a vegetarian.  I am a lacto-ovo vegetarian, meaning I eat dairy and eggs, but do not eat fish, poultry, or other meat.  Lately, I’ve suspected dairy intolerance and have all but cut dairy out of my diet.  So now I guess I’m just an ovo vegetarian.  Or an egg-eating vegan?  Like I said- I’m no good with labels.


One of the most frequent questions I receive about my diet is related to protein intake.  And it’s a legitimate one too; plant-based protein sources are robust, but less obvious than their animal-based counterparts.  Admittedly, people who don’t eat meat need to put a little more effort into ensuring they receive adequate protein.

Last week, I tracked my diet for a few days with SparkPeople and was surprised to discover that I was consistently just shy of their suggested protein minimum (60g/day).  I think that by decreasing my dairy intake, my protein took a hit (Greek yogurt=yum!).  To remedy the situation, I’ve started enjoying a protein shake each morning to get a quick 20g in right off the bat.  I’ve tried hemp protein and Plant Fusion.  To be honest, I’m not crazy about either (“enjoying” might be an overstatement…), but I can make them palatable and it’s worth the effort.

Still, supplements are just that: supplemental.  Here is a list of my 10 favorite lacto-ovo vegetarian sources that I have (at least at some point) incorporated into my diet:

1. Eggs: True, many vegetarians do not eat eggs, but I do!  So versatile, low in calories, and delicious.  High in cholesterol, which is actually a welcome addition to my low cholesterol diet.

2. Beans and Legumes: Black beans, red beans, garbanzos, oh my!  On salads, in tacos, chilli, stew… so many beans, so little time!  Just rinse them first.  This also includes lentils, my fav.

3. Quinoa: It’s actually a seed, but it cooks like rice.  Best. Grain. Ever.

4. Tofu: Great in stir-fry, okay in everything else.  Despite at least a weekly tofu dish, I’ve never figured out how to make it less squishy.  Baking it is the best so far.

5. Tempeh: Another soy product, but so much firmer than tofu.  Even my carnivore husband loves this one!

6. Greek Yogurt: Equivalent to yum, as stated before.  Alone, with fruit, in smoothies, as dip, frozen around grapes.  Close your eyes, and you’re eating ice cream.  Sort of.

7. Garbanzo Flour: I’ve used this a few times with good success: once in a lentil loaf and once to coat tofu before frying.  Seems like a good choice to boost protein in homemade dishes.

8. Protein-enriched Pasta: While not a huge fan of Barilla’s ideals, I still guiltily buy their pasta made with lentil-flour because, as far as I’ve found, they’re the only ones who make it.

9. Edamame: Buy a big bag of these soy beans frozen, and enjoy the perfect snack.

10. Nuts: Whole or in butter form, it’s all good.


So, no, I don’t just eat lettuce and, no, I don’t love every vegetable.  But, yes, I do have many protein sources!  And with some planning and occasional supplementation, they can add up to a pretty healthy diet.  Of course this is not an extensive list.  I would love to hear which vegetarian protein sources you use and how you prepare them.  My diet, like the rest of me, is always a work in progress!