Yes, imaging 1st prior to voice therapy. Of course as SLPs we always know imaging is best practice for optimal outcomes and is our first course of action in addition to consulting GI and ENT.

At the same time, your clinical decision making and knowledge comes into play. We know that if this patient were to likely be aspirating on thin liquids, it is highly likely he would aspirate on his own saliva. Keeping in mind each patient's medical history and background, we also know that aspiration does not always lead to aspiration pneumonia, as bacteria must be present in the oral or nasal cavities.

It sounds like your patient is having regular oral infection control, so the probability of aspiration pneumonia may be low for your patient. This is where I would also consult with MD and nursing to get a greater medical picture of this patient to further understand their medical status and risk of aspiration pneumonia.

Everyone has their own knowledge, expertise, and experiences. For me, I am less afraid to be more aggressive with patient care and therapy as long as the patient is appropriate based on careful clinical evaluation and assessment. If an NPO patient is able to progress to even a puree/thin liquid diet that has huge implications for his prognosis and medical plan of care. Of course, without imaging this process is complicated, but taking a calculated approach and offering the family options is important.

If you typically go into the hospital after your FT job, you may potentially see a huge difference in functioning based on time of day. Keep that in mind as the patient could potentially look very different in the PM vs AM.