The Mixed Consistency Conundrum

There are patients who safely consume thin liquids in isolation and solids in isolation but exhibit signs and symptoms of aspiration with mixed consistencies (which are a solid and a liquid combined). We often see patients return from instrumental exams with a recommendation to avoid mixed consistencies (broth-based soups, cereal with mild, fruit cups, etc.). Common clinical findings during mixed consistency trials are:

• Pharyngeal spillage of liquid prematurely to the pyriform sinuses in the oral preparatory phase of swallowing (during mastication) of the solid component

• Laryngeal penetration of prematurely spilled liquid in the oral preparatory phase of solid component

• Subglottic aspiration of prematurely spilled liquid during mastication of the solid component

• Post-swallow pharyngeal residue in the vallecula or pyriform sinuses

It is important that mixed consistencies are thoroughly assessed during instrumental as well as during clinical (bedside) evaluations, and that we carefully consider interventions that are helpful.

The most common compensatory strategies recommended to improve safety while consuming mixed consistencies are:

• Draining liquid from the spoon

• Use of a fork to eat the solid portion of the mixed consistency first

• Thickening broth or milk

• Pureeing mixed consistencies

• Allowing time for the cereal absorb the milk

It is important that mixed consistencies are thoroughly assessed during instrumental as well as during clinical (bedside) evaluations, and that we carefully consider interventions that are helpful.

Each strategy has its challenges and may not be beneficial for long-term management of mixed consistency dysphagia. The patient has to be cognitively able to recall compensatory strategies or an available caregiver. Draining the liquid portion from the spoon may be tedious. Use of a fork may give the appearance of confusion. Thickening and pureeing mixed consistencies creates additional modification. Allowing cereal to absorb milk does not change the fact that the bolus contains two consistencies.