structural disorders of swallowing adult and children

STRUCTURAL DISORDERS OF SWALLOWING

Adult and Children

Structural Disorders of Swallowing

The largest group of patients with structural swallowing disorders have had oral, pharyngeal, laryngeal, and/or esophageal structures removed, rearranged, or reconstructed secondary to surgery for carcinoma.

Most often, combinations of these structures are involved.

The general rule for predicting significant dysphagic episodes following surgical excision is the 50% rule.

If less than 50 percent of an area or organ concerned with deglutition is removed, this will not interfere seriously or permanently with swallowing function.

The 50 percent rule can also apply if the structure in question is rearranged, or if adjacent structures are rearranged.


Usually procedures on adjacent structures carry a more negative prognosis for deglutitory recovery than does loss of mobility of these structures.

Total or partial loss of sensation, or interruption of the neurologic sensory controls in the oropharynx can be precipitated by surgical procedures.

The use of tissue flaps to close surgical defects interferes with the normal sensation that provides adequate sensory guidance of the bolus needed to affect a normal swallow.

An additional complication is radiation, pre- or post-operatively, which may produce side effects that may farther compromise swallowing.


The 50% rule is only a guide; individual differences should not be overlooked.

In fact, individual differences among patients who have had cancerous lesions and subsequent resections may not be related to the amount of the structure removed.

Factors such as preoperative and postoperative health, psychological reaction to the disability, and the ability to learn adaptive swallowing techniques often have more adverse affects than the cancer surgery itself.

Oral Surgical Resection/Reconstruction

Cancers in the oral cavity may involve the tongue, floor of the mouth, tonsils, soft palate, mandible, and maxilla.

Many times, more than one of these structures is involved.

It is not unusual to have parts of the tongue, mandible, and floor of the mouth resected.

In general, patients with resected oral structures have difficulty with mastication, formation and retention of a bolus, and anterior to posterior lingual transport.

Oral Surgical Resection/Reconstruction

Major resections of parts of the mandible can significantly alter the relationships among oral, pharyngeal, and laryngeal structures, resulting in disturbance of the sequential movements involved in swallowing.

For example, loss of the occlusal jaw relationships after partial removal of the mandible can interfere with mastication in such a way as to lengthen the oral phase of eating.

This can result not only in delayed and, therefore, poorly timed propulsion, but in premature attempts at swallowing because the delay is not well tolerated by most patients.

Partial Tongue Resection

Patients whose surgical resection is small (less than 50%) and limited to the tongue with no other tissue involved, and whose reconstruction is by primary closure will have swallowing difficulties of a relatively temporary nature.


Initially, edema may cause the patient to experience a sense of clumsiness with their tongue in both speech and swallowing, and may contribute to some short-lived difficulties in triggering the swallow reflex.

When resection has included 50% or more of the tongue, lingual peristalsis and control of the material in the mouth will be severely reduced.

The patient will be unable to contact the remaining tongue segment to the palate and thus control the movement of the food.


If the resection is limited to the tongue, and the pharyngeal and laryngeal aspects of the swallow normal, the patient will be able to tolerate a backward tilted head posture without increasing the chances of aspiration.

Anterior Floor of the Mouth Resection

For a tumor found in the anterior floor of the mouth, portions of the tongue, floor of the mouth, and mandible will be removed.

After this resection, the oral phase of the swallow may be impaired but pharyngeal transit will be normal because the surgical defect does not extend posteriorly.


Because the remaining tongue segment is mobile, and the inferior rim of the mandible has been left to maintain its contour, lingual peristalsis is good, and lingual control of the bolus in the oral cavity is essentially normal.

There may, however, be an initial period when post-surgical edema delays oral transit time.

This can easily be compensated for by placing the food more posteriorly on the tongue.

If, however, the floor of the mouth is closed by suturing the tongue into the surgical defect, the patient will be unable to control the bolus, utilize normal lingual peristalsis or masticate.


Because the tongue is sutured down, its anterior range of motion is reduced, and the patient’s ability to cup and hold material in the anterior mouth in preparation for the swallow is severely affected.

Again, this can be compensated for by positioning the food more posteriorly, but because the patient is unable to chew, food will have to be restricted to liquids or pastes.

Some voluntary airway protection may have to be instructed for loose material may fall over the immobile tongue, before a swallow is actually initiated.

Lateral Floor of the Mouth Resection

Patients who have had resection in the lateral floor of the mouth, tonsil, and base of the tongue area, have potential difficulties in both the oral and pharyngeal stages of the swallow.

Because the tongue and other oral structures are involved in the resection, the oral stage of the swallow will be affected.

Lateral Floor of the Mouth Resection

Patients will also have problems with the pharyngeal phase of swallow because of resection to the faucial arches and a portion of the pharynx.

Some of these problems may include, mild to severe disturbances in oral transit time, impaired lingual propulsion of the bolus, food pocketing in the lateral sulci or on the hard palate, delayed swallow response, reduced pharyngeal peristalsis, and possible decreased sensation due to scar tissue.

Usually, unless a fistula has developed in the healing process, laryngeal control of the swallow is normal.

Laryngeal Surgical Resection/ Reconstruction

As with resections of the oral cavity, every patient's surgical resection and reconstruction will be different depending on the areas of involvement.

Generally speaking, approximately 60% of malignant laryngeal tumors occur at the level of the glottis; 35% occur in the supraglottic area; and 5% occur in the subglottic region.

Partial laryngectomy, including supraglottic laryngectomy and hemilaryngectomy, are surgical resections of the pharyngeal and laryngeal regions that seek to control a malignancy while preserving vocal function and deglutition.

Supraglottic Laryngectomy

A supraglottic laryngectomy is the usual treatment for small lesions on the supraglottic larynx, predominantly involving the epiglottis, the aryepiglottic fold or the false vocal folds.


The typical extent of the resection generally includes the hyoid bone and the epiglottis superiorly, and the aryepiglottic folds, and the false cords inferiorly.

This procedure clearly removes the two upper sphincters providing airway protection during swallowing: the epiglottis with its aryepiglottic folds, and the false vocal folds.


Removing these two sphincters leaves the true vocal folds as the only protective mechanism.

In reconstruction, the surgeon generally elevates the remaining larynx and tucks it under for additional protection during the swallow.

Also a cricopharyngeal myotomy is usually performed during the surgical procedures to facilitate swallowing.

Sometimes, the surgical procedure may extend either inferiorly or superiorly, depending on the exact location and size of the tumor.


If the tumor invades the anterior surface of the epiglottis and extends into the base of the tongue, the supraglottic laryngectomy procedure may extend up onto and into the base of the tongue.

These patients will experience a more precipitous drop off the tongue into the airway.


Thus, food or liquid will tend to fall onto the closed true vocal cords, so the closure of the larynx at the level of the true vocal folds must be very strong.

Some patients may be affected by reduced lingual movement and control of the bolus.

In addition, reduced laryngeal sensation may occur because of the need to sacrifice one of the branches of the superior laryngeal nerve, which may affect the cough reflex or the swallow response.


Sometimes the supraglottic laryngectomy extends inferiorly to include part of one vocal cord and the arytenoid cartilage.Chances for recovery of normal swallowing without significant chronic aspiration during the swallow are diminished because this final valve is lost.

Hemilaryngectomy

Tumors located on the free margin of one vocal fold with only local extension are usually treated with the hemilaryngectomy.

Hemilaryngectomy

As the name suggests, the hemilaryngectomy involves the removal of one vertical half of the larynx (see b and c)This resection includes one false vocal fold, one ventricle, and a true vocal fold, excluding the arytenoid cartilage, as well-as a portion of the thyroid cartilage on the side of the resection.

Hemilaryngectomy

The hyoid bone and epiglottis are left intact. Few swallowing difficulties should be experienced

by an individual having this procedure, as some tissue bulk is reconstructed on the operated side, against which the unoperated side can attain normal laryngeal closure during swallowing.

However, the reconstructed side must be at the same level as the normal vocal fold.

Hemilaryngectomy

Location of the tumor may require that the hemilaryngectomy procedure be extended either anteriorly or posteriorly. This lesion is located anteriorly on one vocal fold.

Hemilaryngectomy

The surgical resection will need to include part or all of the anterior commissure of the larynx.In this case the hemilaryngectomy becomes a fronto-lateral laryngectomy including approximately one-third of the anterior portion of the larynx on both sides.

Hemilaryngectomy

If the lesion is located even more anteriorly, the hemilaryngectomy may be extended to include one-half of the other side of the larynx. This becomes a three-fourths laryngectomy. These patients will still have both arytenoid cartilages, a normal epiglottis, and hyoid bone.Tissue bulk is placed on the operated side. If there is sufficient constriction at the level of the true cords and at the epiglottic level, aspiration can be prevented.

Hemilaryngectomy

The hemilaryngectomy may also be extended posteriorly to include the arytenoid cartilage if the location of the tumor so dictates.

Hemilaryngectomy

When the arytenoid cartilage is included in the resection, the patient's chances of returning to normal swallowing with no aspiration are greatly decreased.

Hemilaryngectomy

With any hemilaryngectomy, tipping the patient's head forward will increase the vallecular space between the base of the tongue and the epiglottis.This usually provide sufficient added airway protection to eliminate all aspiration.

Laryngectomy

Large lesions or lesions involving more than one region of the larynx usually require total laryngectomy. Patients who have undergone total laryngectomy, resulting in a physical separation of the gastrointestinal tract from the respiratory tract, do not usually run the risk of aspiration of food or liquid. There are however, two types of swallowing problems that may accompany total laryngectomy. The first is the formation of a pseudo epiglottis formed by a band of scar tissue that develops at the base of the tongue.

Laryngectomy

During swallowing, the peristaltic action of the pharyngeal constrictor muscles pulls the scar tissue band posteriorly.This widens the gap at the base of the tongue and forms a large pocket where food can collect.This structure looks deceptively small on mirror examination of the base of the tongue at rest, but it can widen to essentially occlude the pharynx and prevent material from passing when the patient attempts to swallow. Some total laryngectomees, then, are restricted to liquid food consistency because of this problem.Treatment is generally surgical resection of the scar tissue band.

Laryngectomy

The second type of problem which can occur in the total laryngectomee relates to the tightness of the surgical closure. Patients with lesions in the pyriform sinus or extending into the laryngopharynx will require more extensive resection of pharyngeal mucosa as a part of their total laryngectomy.This necessitates a tighter closure. Some patients will form scar tissue strictures in the esophagus after surgery.

Laryngectomy

The strictures narrow the esophagus sufficiently to prevent any large amount of material or material of thick consistency from passing through the esophagus.Lately, a procedure, developed by Singer and Blom, called a pharyngo-esophageal myotomy after total laryngectomy, releases this scar tissue stricture and permits more normal swallowing.

Pediatric Hypoplasia

Structural impairments in children usually result from underdeveloped structures, such as the tongue and palate.

Infants who have hypoplasia of the tongue may achieve adequate suckle feeding by compensatory actions of the constrictor wall, pharyngeal palate, palatine folds, and hyoid suspensory muscles.

The mandible and palate, as well as other portions of the midfacial skeleton are adapted in shape to form functionally appropriate chambers around the hypoplastic tongue.


Similarly, the infant with cleft palate, but who has normal feeding incentive and normal sensory inputs and central representations of suckle and swallow, may demonstrate remarkable motor compensations for this anatomic defect.

In contrast, the infant who has palatal hypoplasia, evidenced by cleft of the uvula or by a palate that is visibly short or lax under fingertip palpation, may have great problems of pharyngeal dysphagia, including nasal regurgitation.


Most children who have structural problems of the oral and pharyngeal areas are expected to continue to develop as long as there is adequate neurologic mechanisms for postural, respiratory, and feeding functions.

Anatomic adaptations of the facial skeleton will also continue during childhood and pubertal growth.

Structural Disorders of the Esophagus Typical manifestations of abnormal esophageal

function in the child are eating difficulties, pain, or regurgitation.

Since the esophagus is composed of both striated and smooth muscle, abnormalities of esophageal motility can involve either muscle type or both.

Disorders of esophageal function can be either primary or secondary to systemic disease.

The symptoms and signs that most commonly suggest a disorder of swallowing or esophageal function in children are dysphagia (including food refusal), abnormally slow eating, persistent drooling, posturing during swallow, chest pain or odynophagia, recurrent aspiration, and recurrent food impaction.

Structural Disorders of the Esophagus Achalasia (incompetently relaxing or non-

relaxing LES) and chronic intestinal pseudo-obstruction are the most common primary esophageal motility disorders in children, but both occur infrequently.

Childhood achalasia appears to be more common in boys, and familial cases are rare.

One study indicates that regurgitation of food and dysphagia are the most frequent symptoms in affected children.

Eighteen percent of patients experienced onset of symptoms during infancy, but only 6% of the patients were identified as having achalasia during infancy.

Mechanical Disorders of Swallowing

Patients with mechanical swallowing disorders evidence difficulty with swallowing behaviors secondary to the loss of sensory guidance of the structures necessary to complete a normal swallow. Nonetheless, their central and most of their peripheral neurological controls of deglutition are intact.

Irradiation and Radiotherapy

It is not infrequent for patients who undergo surgical resections for carcinoma to also receive preoperative or postoperative radiotherapy.These treatment may produce some side effects that may further compromise swallowing. Side effects may include:

oral and pharyngeal inflammation;pain in the soft tissues and bone;drying of the mucosal tissues;diminished volume and thicker consistency of saliva;changes in taste sensation; and loss of appetite.

Loss of Saliva Flow (Xerostomia)

If radiotherapy is directed towards the salivary glands, patients will experience marked reduction in saliva flow. This is called xerostomia and can be permanent and irreversible.When the salivary glands can no longer produce a normal mixture of serous and mucous saliva, deglutition is affected by:

increased dental caries due to loss of the natural defense against decay; and accumulation of stringy mucous that has lost its lubricating abilities. Dental caries create pain during mastication if left untreated.

Loss of Saliva Flow (Xerostomia)

Decay can begin on any tooth and progress rapidly toward destruction of the dental crown. Accumulation of thick mucous can in itself mechanically interfere with swallowing.

Mucositis

Radiotherapy can produce significant inflammatory changes in the mucous lining, resulting in tenderness and burning not unlike a severe sore throat. A more marked form of these complaints may surface as mucositis. When the pain spreads to the pharyngeal mucosa, swallowing can be difficult. This discomfort may be antagonized by coarse and highly seasoned foods. Mucositis gradually improves over time.

Osteoradionecrosis

Osteoradionecrosis can result from oral mucosal destruction at the primary site of radiation. Developing fibrosis and reduction of blood supply result in the formation of necrotic ulcers that, if left untreated, can invade bony structures through infectious processes. Ulcers can develop two to three months after radiotherapy or any time thereafter. The resultant pain can impair oral feeding actions and swallowing to the point at which patients are unable to take nutrition orally. Patients are most vulnerable to osteoradionecrosis of the jaws during the two years following irradiation.

Trismus

Trismus is a form of tonic spasms affecting the muscles of mastication.It usually occurs during or following radiotherapy.Jaw excursion becomes quite painful and limited. This is thought to be secondary to masticatory muscle fibrosis.

Loss of Taste

A common complaint among at least a little better than half of all irradiated patients is loss of appetite either during or shortly after treatment. Some patients experience a loss of taste which causes them to be less interested in food.Others experience a feeling of nausea and general dissatisfaction with their diets. Somewhere after 4 months of termination of radiotherapy, the sense of taste acuity should return, although some specific losses of sweet, salt, and bitter tastes may be noted.

Loss of Taste

Aversions to meat and vegetable proteins have also been noted. Such aversions can lead to loss of appetite, disinterest in food, and eventually, to poor nutrition. Severe loss of proteins, calories, vitamins, and minerals can lead to a nutritional deficiency type of stomatitis (inflammation of the mouth).

Infectious Inflammations

Acute inflammatory processes that produce or exacerbate dysphagia are nonspecific reactions to injury of the oropharyngeal tissue secondary to bacterial or viral agents, chemical irritants, or traumatic insults.For example, herpes simplex, a viral herpetic infection, is characterized by round vesicles that break to form shallow ulcers surrounded by a zone of inflammation. Typically, they are on the lips; however, the pharynx and buccal mucosa may be involved. Palatal and pharyngeal ulcers create significant pain and discomfort on swallowing.

Fungal Inflammation

One of the most common fungal inflammations is candidiasis/moniliasis (thrush). Most frequently seen on the tongue, the lesions appear as soft, white, slightly elevated plaques.If left untreated, the lesions cause associated pain and difficulty swallowing. They are more common in debilitated patients, in those who are undergoing extensive antibiotic therapy, and in patients receiving irradiation treatments.

Chemical Inflammation

Chemically-induced inflammation can result from prolonged use of phenol (toothache drops). Other drugs that precipitate mucosal burns include aspirin, which causes irritation to the cheek lining, some gargles, and anesthetic throat lozenges when used excessively.Anesthetic throat lozenges reduce oral sensation and invite traumatic lesions from persons who unknowingly bite their oral mucosa. Mucosal burns can be red or white but represent a change in the normal pinkish mucosal lining.More severe inflammations have a whitish slough covering an intensely reddened area.

Chemical Inflammation

The most severe form of chemical burn, lye ingestion, can cause severe blistering of the entire digestive tract.Also drugs commonly used in chemotherapy, such as doxorubicin, methotrexate, and cyclophosphmide can cause oral mucositis and the development of painful ulcerations.

Tracheostomy & Dysphagia

Tracheostomy, with or without ventilator dependency, is frequently seen in patients with a variety of neuromuscular pathologies.

Damage to the CNS, specifically, the cerebrum, brainstem, and/or spinal cord, due to head trauma, infarction, glioma, and/or a high cervical lesion may necessitate the need for a temporary and/or permanent airway assistance.

Damage to the PNS, specifically the lower motor neuron and/or cranial nerve, from poliomyelitis, ALS, or Guillain Barre syndrome may also result in the need for a temporary and/or permanent airway assistance.

Finally, damage at the neuromuscular junction, due to botulism, MG, or muscular dystrophy, may comprise the airway.


Whether tracheostomy tubes adversely affect swallowing remains unclear because results in the literature are equivocal.

Estimates of the number of individuals with tracheostomy and concomitant oropharyngeal dysphagia have been reported to be as high as 87% (Pannuzio, 1996).

In addition, many patients with tracheostomies have other medical factors, such as chronic obstructive pulmonary disease, that could predispose them to difficulty swallowing.

Trach tubes may cause some patients to aspirate and not others, depending on diagnosis and other underlying factors.

Trach tubes, however, can tip some at-risk patients over the edge.


An additional complication is that the presence of the tube, especially if unfenestrated, prevents expiratory air from being shunted superiorly.

This results in a decrease of expired air needed to clear the larynx after swallowing.

Studies have also found that in chronically trached canines, there was diminished activity of the thyroarytenoid muscle and reduced laryngeal adduction force (Sasaki, Suzuki, Horiuchi & Kirchner, 1977).


Moreover, a signficant reduction in motor unit activity for both abduction and adduction was measured in the intrinsic laryngeal muscles when airflow was diverted from the larynx (Adzaku, 1980).

Regardless of whether there is a direct causal relationship between tracheostomy and dysphagia, many individuals with tracheostomy tubes do aspirate.

A number of options, including cuff deflation, tracheostomy tube occlusion, and one way speaking valve placement, have been introduced to reduce or eliminate the risk of aspiration in this patient population.


Some researchers (Betts, 1965; Mehta, 1972; Tippett & Siebens, 1991) have suggested that the presence of inflated tracheostomy tube cuff adversely affects swallowing either by tethering the larynx and reducing hyolaryngeal excursion and airway closure during the swallow or by impinging on the tracheoesophageal wall with air pressure and impeding the passage of food or liquid through the esophagus.

Tippett and Siebens (1991) examined the effects of cuff deflation on swallowing in five individuals with tracheostomy tubes who were ventilator-dependent.


They found that 3 of 5 participants were able to safely swallow when their cuffs were deflated and their ventilator settings were adjusted to facilitate swallowing.

Because of the additional adjustments in ventilator settings, it remains unclear if cuff deflation alone had any significant effect on swallow status.

Suiter, McCullough, and Powell (2003) examined the effects of cuff deflation on swallow function in 14 individuals who were not on mechanical ventilation.

Participants completed a VFSS with and without the tracheostomy cuff inflated.

All participants aspirated thin liquids during the cuff-inflated condition.


Swallows were analyzed for seven swallow duration measures, extent of hyolaryngeal excursion, oropharyngeal residue, and penetration-aspiration, using an 8-point scale (Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996).

Pharyngeal transit duration and duration of hyoid maximum anterior excursion were significantly longer when the cuff was deflated, and duration of cricopharyngeal opening was significantly shorter when the cuff was deflated.

Mean maximum hyoid anterior movement was significantly greater during the cuff deflated condition.


Ding and Logemann (2005) completed a retrospective study with 623 participants who completed VFSS under one condition only: either with or without the tracheostomy cuff inflated.

Swallows were analyzed for the presence or absence of the several physiological events.

There was a higher incidence of aspiration, silent aspiration, and reduced laryngeal elevation in participants who swallowed with their cuffs inflated.


Muz, Mathog, Nelson, and Jones (1989) completed scintigraphy in 7 participants with head and neck cancer and tracheostomy when the tracheostomy tube was open and when the tube was occluded by an obturator.

One participant did not aspirate under either condition; 2 aspirated under the tracheostomy tube open condition only; and 4 participants aspirated under both conditions, but aspirated significantly less when the tracheostomy tube was occluded.

Overall, the incidence and severity of aspiration during the tracheostomy tube open condition was significantly greater than during the tracheostomy occluded condition.


In a larger 1994 study, Muz, Hamlet, Mathog, and Farris again used scintigraphy to examine swallow function in 18 patients with head and neck cancer and tracheostomy under two conditions: 1) occluded tracheostomy tube, and 2) open tracheostomy tube.

Like the earlier study, there was a significant reduction in the percentage of aspirated material during the tracheostomy occluded condition than during the open tracheostomy condition.

Logemann, Pauloski, and Coleangelo (1998) examined the effects of digital occlusion of the tracheostomy tube in eight patients with head and neck cancer.

Findings were similar to those found for obturator occlusion of the tracheostomy.


Six of the 8 participants aspirated thin liquids and/or paste consistencies when the tube was open, and three of the six had aspiration eliminated when the tube was digitally occluded.

Two participants had no change in aspiration status between the two conditions or an increase in aspiration when the tracheostomy tube was occluded.

When the tube was occluded there was reduced duration of tongue base to posterior pharyngeal wall contact, increased laryngeal elevation, increased laryngeal and hyoid elevation at the time of cricopharyngeal relaxation, and delayed anterior movement of the posterior pharyngeal wall in relation to onset of cricopharyngeal opening.

Speaking Valves and Swallowing Patients with tracheostomy tubes are sometimes

able to tolerate one-way speaking valve placement. The main purpose of speaking valve placement is to

allow the individual to phonate. However, a number of additional purported benefits

of valve placement have been reported, including: decreased oral and nasal secretions; increased food intake; and increased energy levels (Lichtmann et al., 1995; Manzano

et al., 1993; Passy, Baydur, Prentice, & Darnell-Neal, 1993).

In addition, speaking valve placement may facilitate weaning from mechanical ventilation (Frey, 1991).

Speaking Valves and Swallowing

A number of studies have indicated that placement of a one-way speaking valve also helps eliminate or reduce aspiration in patients with tracheostomy.

Speaking valve placement offers several advantages over digital (finger) occlusion, including: increased sanitation (i.e., there is a risk of con tamination

when a tracheostomy tube is digitally occluded); less conscious effort for the patient (i.e., the patient does

not have to coordinate digital occlusion with respiration); and

reduced respiratory load when compared to complete tracheostomy occlusion with a tracheostomy cap.


Placement of a one-way speaking valve may resolve several of the potential factors related to tracheostomy that may adversely affect swallowing.

First, speaking valve placement requires that an individual's tracheostomy cuff be deflated.

This would reduce the potential for tethering of the larynx, which a number of researchers (Betts, 1965; Mehta, 1972; Tippett & Siebens, 1991) have suggested occurs in the presence of an inflated tracheostomy cuff.

Second, speaking valve placement allows air to flow through the upper airway, including the vocal folds.

This may restore laryngeal sensation and airway clearance.


Finally, valve placement may help increase subglottal pressure, which is diminished when the tracheostomy tube is open (Eibling & Gross, 1996; Gross, Mahlmann, & Grayhack, 2003).

Gross, Dettelbach, Zajac, and Eibling (1994) measured subglottal air pressure with the tracheostomy tube open and with a speaking valve in place.

Results indicated a ten-fold increase in subglottal pressure during swallowing with the speaking valve in place compared to subglottal pressure with the tracheostomy tube open.


These authors have suggested that a reduction in subglottal pressure is the main mechanism responsible for the high incidence of aspiration in patients with tracheostomy (Eibling & Gross, 1996).

Despite a large body of evidence suggesting favorable effects of speaking valve placement on swallowing, there are confounding reports.

The specific effects of one-way speaking valve placement on swallow physiology have not been determined.

Overall, most reports in the literature indicate that the speaking valve placement improves swallow safety.


It is possible that the speaking valve placement restores laryngeal and pharyngeal sensation, because it allows for the flow of air through the upper airway.

Improved sensation should lead to improved swallow safety.

The effects of speaking valve placement on laryngeal and pharyngeal sensation need further study.

Pediatric Tracheostomy

• An estimated 4,861 tracheotomies are performed yearly on pediatric patients in the United States (Lewis, Carron, Perkins, Sie, & Feudtner, 2003).

• Over half are performed on children between the ages of birth and 11 months (Carron, Derkay, Strope, Nosonchuk, & Darrow, 2000; Lewis et al, 2003).

• The majority of the current population of children with tracheostomies are 2 to 3 years of age.


• Children cannulated for prolonged ventilation tend to be younger, with a mean age of 1.4 years, and the duration of cannulation tends to be greater than 24 months (Carron et al., 2000; Hadfield, Lloyd-Faulconbridge, Almeyda, Albert, & Bailey, 2003; Pereira, MacGregor, McDuffie, & Mitchell, 2003; Wetmore et al.).

• However, children with craniofacial anomalies cannulated for upper airway obstruction and those cannulated secondary to trauma are more likely to be decannulated in less than 24 months.

• Unfortunately, children with neurological impairments and tracheostomies typically remain cannulated for an average of 46 months (Carron et al., 2000).


• The most common ages at which tracheostomies are placed in children include the years critical to the acquisition and development of language, speech, and oral feeding skills.

• However, few investigators have recognized that children with tracheostomies have problems with oral ingestion (Abraham, 2005).

• Even fewer have investigated the effects of long-term cannulation on swallowing physiology and feeding development in infants and young children.


• Part of the difficulty in researching the trach’s effect on pediatric swallowing has to do with human subjects treatment guidelines and controlling for confounding variables, such as the underlying medical diagnosis and reason for tracheostomy. • The lack of normative data for pharyngeal stage

swallowing physiology in young, pediatric patients further exacerbates the problem. • Prescott and Vanlierde (1989) reported 5% of 293

patients with tracheostomy, ages newborn to 12 years, had laryngeal incompetence when feeding was resumed after tracheostomy.

Pediatric Trachestomy

• Arvedson and Brodsky (1992) found that 48% of 29 patients with tracheostomy, ages one month to 17 years, who were referred for speech and language evaluations during an acute inpatient stay, had swallowing problems. • Again, the swallowing deficits were not described,

although there was reportedly a high incidence of CNS involvement which could lead to underlying neurophysiologic factors affecting swallowing. • Recent clinical investigation into a "trach effect"

has utilized instrumental measures rather than relying on clinical measures alone.


• Willging (2000) utilized FEES to assess feeding abilities in 255 patients with a median age of 2.5 years (range: one week to 51 years).

• Of the 255 subjects, 53% had tracheostomies.• Willging found a higher incidence of enteral

feeding in the patient group with tracheostomies than in the patient group without tracheostomies.

• Abraham and Wolf (2000) utilized VFSS to investigate the effects of long-term tracheostomy on swallowing physiology in a select group of four toddlers aged 1;2 to 2;9 years.

• The participants had functional cognitive and motor skills without anomalous upper airways.


• A normal-developing patient aged 1;2 years with no tracheostomy served as a toddler model for purposes of comparison.

• All 5 subjects were oral only feeders on bottle feeds of thin liquids, spoon feeds of purees, soft chewables, and finger foods.

• The toddlers with tracheostomies had no confirmed superior excursion of the larynx and arytenoid associated with the swallowing response.

• They displayed slowing of supraglottic airway closure for timely bolus swallows of liquid and puree.

• Specifically, the toddlers with tracheostomy showed a prolonged time line to close the laryngeal vestibule once the arytenoids began their anterior excursion.


• There were also differences in timing of supraglottic airway closure and UES opening.

• Closure of the laryngeal vestibule occurred after UES opening in the toddlers with tracheostomies, whereas closure occurred before or within the same time frame as UES opening in the toddler with no tracheostomy.

• Subsequent additions to the original cohort who met criteria for inclusion (N = 10) also showed increased time line for closure of the laryngeal vestibule when compared with children without tracheostomies.

• These findings suggest that movement of the supraglottic structures during the act of bolus swallowing is slower and tends to be more restrictive in young children with long-term tracheostomies.


• Therefore, during examination of an infant or young child with a tracheostomy, an inability to palpate laryngeal movement or the observation of severely restricted movement of the larynx associated with bolus ingestion may be a sign of a swallowing disorder.

• VFSS may be warranted to rule out slowing of laryngeal vestibule closure, reduced laryngeal excursion, and airway contamination resulting from these deficits.

• A "trach effect" on the airway may be readily observable in the secretions and secretion management of young pediatric patients with tracheostomy.


• All infants and young children with open tracheostomy tubes have secretion issues.

• A notable increase in secretions with concomitant decrease in the ability to manage secretions is typical of tracheostomized infants and young children.

• Management of secretions in the upper airway as well as in the lower airways is critical to maintaining upper airway patency and pulmonary health.

• Nasal breathing, which humidifies, warms, and filters inspired air, is by passed when a tracheostomy is in place.

• Air that flows into the tracheostomy is dry, cold, and unfiltered.


• Lack of humidified and filtered air frequently leads to increased viscosity of mucous and other complications, such as inflammation of the upper airways.

• Suctioning is needed because of decreased intra-thoracic pressures and loss of effort closure by the larynx in the open tube mode.

• Frequent suctioning irritates the lower airways and increases secretion production (Mason & Meehan, 1993).

• A "wet trach" with mild, intermittent accumulation of clear, nonpurulent tracheal secretions and no laryngeal secretion accumulation is an acceptable secretion baseline for an infant or a young child with a tracheostomy.


• Chronic laryngeal and/or tracheal secretions with recurrent need for suctioning in the home 10 or more times a day, or copious secretions throughout the upper airway, is an abnormal secretion baseline. • Situations in which infants and young children

have "dry trachs"—that is, no audible tracheal or laryngeal secretions over time—can lead to mucous plugs that can occlude the tube and restrict respiration.


• With respect to clinical practice, any change in laryngeal and/or tracheal secretions associated with oral feeds is a remarkable finding.• Although it is important to evaluate all textures

and utensils in use, directed observation of a full feed from a bottle should take precedence. • It is best accomplished using the child's formula,

rather than juice or water. • Any secretion build-up or accumulation at the

level of the larynx and/or trachea during or after oral ingestion is an indication of a swallowing disorder.


• Instrumental evaluation is required to determine the specific swallowing deficits.

• Management decisions range from determining the feasibility of continuing oral only feeds to modifications to current oral feeds.

• Options depend on the patient's swallowing deficits, medical course, and current medical status, in particular, his/her airway, nutrition, and respiration.

• Aside from decannulation, the most effective treatment for the adverse changes to secretions and their management secondary to tracheostomy in infants and young children is placement of a one-way speaking valve by Passy-Muir, Inc. (Abraham, 2003; Waldowski, 2002).

Airway Protective Responses

• A "trach effect" on airway protective responses in infants and young children with tracheostomies can be readily observed in the reflexive cough.

• The reflexive cough to clear laryngeal and/or tracheal secretions can be very delayed or absent in pediatric patients with tracheostomy.

• Some children with tracheostomies cough only in association with cannula suctioning or require deep suctioning to elicit a cough.

• Others simply have no cough with a cannula in situ.


• Because of the trend away from tracheostomy for short-term management toward pediatric tracheostomy for long-term airway management (Wetmore et al., 1999), the potential for a "trach effect" on airway protective responses is heightened.

• Any aberrant reflexive cough response on clinical examination of tracheostomized infants and young children, whether it be a delayed or an absent cough in the presence of audible laryngotracheal secretions or a cough elicited only by suctioning, warrants therapeutic intervention.


• Instrumental evaluation is needed to rule out airway contamination.

• Airway Protection Techniques (APTs) proposed by Kagel (1996) and modified for neurodevelopmental age should be initiated early in the treatment process, because they are effective in eliciting a cough response with a post-cough swallow to clear laryngotracheal secretions in young children with tracheostomies (Abraham, 1997).

• APT facilitators for children with tracheostomies include offering single swallows of water or pairing "occlude-release" with the word "cough" in the presence of audible laryngeal and/or tracheal secretions.


• Treatment effectiveness and carryover of modified APTs are optimized when the child tolerates consistent placement of a one way speaking valve and effort closure of the larynx is restored.

• Modified APTs using the throat clear require audibility of laryngeal frication and more advanced neurodevelopment than modified APTs using the cough response (Abraham, 2005).

VFSS Special Considerations

• Issues of patient compliance are commonplace during VFSS with any young pediatric patients.

• The presence of a feeding disorder of refusal and/or selectivity can further compromise compliance during VFSS.

• In depth videofluoroscopic analysis of swallowing physiology in infants and young children with tracheostomies requires visualization of structures in the highest magnification mode of the fluororadiography system.


• Anatomic markers that should be within the fluoroscopic field include the nasal and nasopharyngeal passages superiorly, the lips anteriorly, the cervical spine posteriorly, and the trach tube inferiorly.

• Unfortunately, there are young children in whom size, positioning and/or angling of upper airway structures coupled with positioning of the trach tube in the trachea preclude visualization of the cannula as well as the other anatomic markers.


• When magnification is decreased to facilitate inclusion of key anatomic markers, analysis of structural movements, their timing, as well as visualization of trace aspirants can be compromised.

• Furthermore, the neck flange of the tracheostomy tube can obscure visualization of the laryngeal structures.

• Another variable unique to infants and young children with tracheostomies is the need to prevent aspiration into the tracheostomy tube from external sources during the VFSS procedure.


• There can be spillage of barium from the oral cavity secondary to a feeding disorder and/or a swallowing deficit as well as accidental spillage from the dispensing utensil itself.

• Of primary concern is the spillage of contrast material from the mouth, chin, or cheeks inferior to the hub of the tracheostomy tube, because it can easily and rapidly enter the cannula and be aspirated directly into the trachea.

• Another variable unique to infants and young children with tracheostomies that can adversely affect the fluoroscopic study is external spillage of contrast material onto the tracheostomy ties.


• Any spillage from the mouth, face, or utensil can quickly drain inferiorly onto the patient's tracheostomy ties. • Contrast material on the tracheostomy ties (some

of which are a half-inch or more in width) can obscure critical views of swallowing physiology, because of the positioning of the ties around the neck. • So external spillage of contrast material during

VFSS with infants/young children with trachs can result in serious consequences to the patient, obscure fluoroscopic images for in depth analysis, and preclude continuation of the procedure. • Precautionary measures are warranted for this

special population.

Nasogastric Tubes

Nasogastric feeding tubes also interfere with normal swallowing by altering sensations in the pharynx and deflecting the bolus. A tube passing transnasally may force the patient to breathe from the mouth, thus drying the mucosa and additionally impairing normal reflexes. The most frequent complication of nasogastric feeding is aspiration of food or gastric contents.Symptoms of aspiration include increased respiratory rate with labored breathing, pulmonary congestion with decreased breath sounds, cyanosis, and sweating.

Nasogastric Tubes

These patients may also manifest a persistent low-grade fever. Continuous feeding with NG tube raises gastric pH to 4 instead of the normal 2.2Bacteria grows up the esophagus and then invades the lungs.

Nasogastric Tubes

From the standpoint of patient comfort and fewer complications, the smaller size (10 French) is preferred. Patients with larger feeding tubes (16 to 18 French) tend to experience more frequent esophageal ulceration, especially if they are employed for an extensive length of time.