Effect of Vocal Fold Paralysis on Swallowing Safety

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					Effect of Vocal Fold Motion
 Immobility on Swallowing
           Safety

  Tessa Goldsmith, MA CCC/SLP, BRS-S
     Massachusetts General Hospital
              Boston MA
Two unusual consultation requests:
1.Swallowing evaluation on endotracheally
  intubated patient
2. T- tube through vocal folds




      Voiceboxdoc.com
What questions did these two patients
raise?
 How is swallowing possible when the vocal
 folds are stented open?
 Why do some patients with vocal fold
 paralysis aspirate and others don’t

 Have to go back to the basics!
Vagus CN X
 Superior Laryngeal Nerve
 Recurrent Laryngeal Nerve
 Mixed motor, sensory and autonomic
 nerve
 Innervates adductor and abductor muscles
SLN anaesthesia symptoms –Globus
Pharyngis
 Labored or effortful swallowing
 Symptom of persistent fullness or swelling
 in the throat
 Need to swallow forcefully to clear bolus
 No evidence of obstruction on VFSS
   No cricopharyngeal hypertonia
 Illusory enlargement of an anesthetized
 body part explained by enlarged cortical
 somatosensory maps
SLN
 Concluded:
  ISLN damage can result in increased risk for
  aspiration
  But since component parts such as vocal fold
  closure can be unaffected during voluntary
  events, pt can develop adaptive maneuvers
  such as SSGS to increase airway protection
  after SGL
Causes of Vocal Fold Immobility
    Vascular insults
    Viruses
    Bacterial infections
    Neurotoxic drugs
    Tumors
    Trauma
    Fixation of cricoarytenoid joint
SURGICAL CAUSES
 Thermal damage        Carotid
 Stretch               endaterectomy
 Cutting               Thyroidectomy
 Compression           Anterior approach to
 Vascular compromise   cervical spine
                            Vs
 Problems frequently
                       Skull base surgery
 not recognized at
 surgery               Thoracic surgery
Percentage Vocal Fold Immobility




   Benninger et al, Otolaryngol Head Neck Surg 1994; 111:497
Affleck et al (2003)
Unilateral RLN paralysis after thyroid surgery
3.5%
Airway protection: Order of events
 Top down?
 Bottom up?
  Ekberg (1982)
    Cineradiography
    Informs today’s
    thinking
Order of events
 Something different?
   Shaker et al (1990) simultaneous VFSS and
   FEES
     TVF’s closed before laryngeal elevation
     TVFs closed before tongue base retraction and hyoid
     elevation
     1/3 of swallows TVF’s open at time of hyoid elevation
     Close, open slightly and then adduct as larynx elevates
   Ohmae et al (1995) simultaneous VFSS and
   FEES
     Arytenoid adduction first event in 86% of swallows
     Vocal folds not closed until laryngeal elevation is
     underway
   Problem – whiteout on endoscopy
Order of events
 Van Daele et al 2005
 EMG (hooked wire and surface) and endoscopic
 analysis
   Arytenoid adduction with epiglottic tilt, cessation of PCA
   activity
   Hyolaryngeal elevation
   Tongue retraction – genioglossus activity
   Pharyngeal elevation and constriction
   Vocal fold closure (TA onset)
   Contraction of suprahyoids
 Nature of dysphagia in Patients with
vocal fold motion impairment
 None
 Mild dysphagia
 Diminished cough strength in the face of
 laryngeal penetration or aspiration
 Heitmiller et al
   Aspiration in 38% of cases
   Laryngeal penetration in 12 % of cases
Incidence of dysphagia in vocal fold
motion immobility
 Leder and Ross (2005)
   Prospective study of 1452 patients referred
   for dysphagia eval
   5.6% or 81 pts had VF immobility
     25/81 (31%) R VF
     49/81 (60%) L VF
     7/81 (9%) B VF
   44% or 36/82 had aspiration
   Aspiration more often on liquids
   Side of vocal fold immobility was not
   significant in relation to aspiration
Aspiration rates
 23-35% aspiration on videofluoroscopy
   Nayak et al 23%
   Bhattacharyya et al 23%
   Heitmuller et al 38%
   Perie et al 53%
   Tabhee et al 35% on liquids


 Aspiration not the only swallowing impairment
 Pharyngeal weakness also a contributor
Incidence of dysphagia in vocal fold
Motion immobility
 Bhattacharyya et al 2000
   64 subjects, newly diagnosed VFMI
   31% Pen, 23% Asp
   Penetration-Aspiration score 2.0
   Pen occurred during swallow
   ½ of patients aspirated after the swallow
   from pharyngeal residue
Incidence of dysphagia in vocal fold
Motion immobility
   Found statistical significance
   between higher PAS score and
   pharyngeal residue
   Open glottis during the swallow
   would deflate hypopharyngeal
   sump pump pressure for bolus
   propulsion
Incidence of dysphagia in vocal fold
Motion Immobility contd.
   Cause of VFMI was not significant in PAS score
   But patients with high vagal lesions
   (intracranial causes) have higher PAS score
   No improvement in swallowing function after
   medialization thyroplasty or Gelfoam injection
   Some patients had worse PAS scores
   Greatest value of medialization may lie in
   increased cough strength
Role of sensation
 Tabhee et al 2005
 FEEST on 78 subjects
 45 males, 36 females, Mean age 59 years
 Cohort
   Iatrogenic 42%       Malignancy 23%
   Neurological 18%     Other 18%
 Mechanism of injury
   Vagal nerve injury 40.7%   RLN injury 25%
   Other 28.4%
Role of sensation
 Findings
   60% had trouble with secretions
   62% impaired pharyngeal squeeze
   83% decreased laryngopharyngeal sensation
      57% bilateral, 26% unilateral and ipsilateral to injury
   32% of patients unilateral absence of LAR
   35% aspirated liquids
 Higher aspiration rates in patients with decreased
 sensation and reduced LAR
Swallowing Function following
Medialization procedures
Bhattacharrya et al 2002
    67 subjects with UVFMI
    underwent medialization procedures
       Type I Thyroplasty
       Gelfoam injection
  Found 44.8% aspiration, 23.9% penetration after
  surgery
  Swallow delay, pharyngeal residue, reduced
  hyolaryngeal elevation
  Concluded that impaired laryngeal closure not
  only cause of aspiration/laryngeal penetration
Case studies
 Patient with vocal fold immobility with
 normal swallowing
 Patient with vocal fold mobility with
 abnormal swallowing
Treatment
 First goal – safe oral feeds

 Look at the whole patient

 Identify pathophysiologic substrates
 of the following signs
   Laryngeal penetration
   Aspiration
   Residue
Treatment
 Postural changes
   Head rotation to affected side
   Chin down posture
 Swallowing maneuvers
   Super supraglottic swallow
 Postural changes and maneuvers
 together
Take home messages
VFMI alone does not predict for aspiration

Assess motor and sensory components

Endoscopic evaluation

Restoration of cough function
Initial stages may be compensatory
treatment