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92 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
FIGURE 3–12. A 68-year-old male with unilateral (L) vocal
fold partial paralysis (UVFP) following anterior cervical spine
surgery.
TABLE 3–11. Etiological Factors for Postoperative
Dysphagia After Anterior Cervical Spine Surgery
Muscles of Tongue,
Pain
Edema Tongue, pharynx, larynx, neck
Hematoma Retropharyngeal space
Infection/abscess Retropharyngeal space
Interruption of motor
innervations
Pharynx/Larynx (post-ET)
Ansa cervicalis
RLN
Pharyngeal plexus
A list of common complications identified by
Dornbos et al
62
found 100% of patients with ACSS
experience at least 1 month of dysphagia following
surgery and as many as 11% with dysphagia lasting
up to 1 year. These are summarized in Table 3–12.
The surgical complications, side effects, and
sequelae that may affect deglutition include edema,
hematoma formation, infection, and denervation.
The following are the most common:
1. Prevertebral soft tissue swelling and associ-
ated reduced epiglottis inversion may result
in dysphagia following ACSS. Swelling of the
posterior pharyngeal wall or a prevertebral
hematoma may cause displacement of the
pharyngeal wall toward the epiglottis, preventing the epiglottis from inverting. This causes
a transient obstruction that traps the bolus,
resulting in residue at the valleculae and
piriform sinuses.
2. Hypertonicity of the UES, as diagnosed by
manometry, results in dysphagia following
ACSS. Hypertonicity of the UES may prevent
passage of the bolus into the esophagus,
resulting in pharyngeal residue. It may be
caused by direct inflammation to the muscle,
by retraction or dissection, or by parasympathetic (vagal) denervation. Hypertonicity of
the UES may be secondary to gastroesophageal reflux disease (GERD). This should also
be ruled out prior to surgery or treated with
medication and an antireflux diet.
Interruption of
neuromuscular function
Injury to sensory
innervations
Mechanical factors Perforation
Velopharyngeal
incompetence
Abbreviations: ET, endotracheal tube; RLN, recurrent laryngeal nerve;
SLN, superior laryngeal nerve.
Anterior tongue
Base of tongue
SLN
Pharyngeal plexus
Bulky reconstruction plate
Adhesions — posterior
pharyngeal wall
Palatal shortening
Wound breakdown
TABLE 3–12. Complications of Anterior Cervical Spine
Surgery Approach
Early dysphagia (≤1 month): 100%
Prolonged dysphagia (≥12 months): 5%–11%
Hematoma: 1%–3%
RLN injury: 1%–16%
SLN injury: 1%
Esophageal perforation: 0.2%–0.9%
Abbreviations: RLN, recurrent laryngeal nerve; SLN, superior laryngeal nerve.
a
Adapted from Dornbos, Seim, and Mendel.
a
62
3. SWALLOWING DISORDERS ARISING FROM NEUROLOGICAL DISORDERS AND OTHER DISEASES 93
3. Esophageal perforation is a rare but serious
cause of dysphagia following ACSS (approximately 1 in 500). A perforation is often not
recognized until the patient develops an
abscess or tracheoesophageal fistula in the
immediate postoperative period.
4. Size and positioning of the bone graft and/
or plate during ACSS must be optimal so
there is not impingement on or compression
of the posterior pharyngeal wall. The use of
bone grafts or plates that produce a bulge
of the posterior pharyngeal wall may lead to
dysphagia or to the sensation that the bolus
is not passing into the lower esophagus but
remaining in the laryngopharynx or upper
esophagus.
5. Screw or plate displacement or extrusion
following ACSS also may result in dysphagia.
This may not be readily noticed if the screw
loosens slowly. When dysphagia occurs some
time after surgery, a loose or loosening screw
must be considered. Repeating the surgical
procedure and removing or replacing the
screw corrects this.
mon short- and long-term complication, regardless
of the patient’s age, type of surgery, or preoperative
diagnosis.
Long-term effects of cervical spine surgery are
often the result of surgical complications. These may
be increased due to the age of the patient, specific type of surgery, or postoperative complications
unrelated to the surgery.
Case Vignette
Mr. J, age 63 years, underwent an ACSS for a C3
injury. He was put on a liquid diet following the
surgery. The next morning, his family brought him
his favorite bagel with coffee. After one bite of
the bagel, Mr. J was immediately rushed to the
emergency room where the bagel was removed
from his airway. He was then sent back to
surgery to have the surgically placed plate reset.
Mr. J had a relatively long rehabilitation period
following the second surgery.
In some cases, dysphagia after ACSS can be
addressed immediately with diet modification, and
no long-term treatment is necessary. The assessment process ultimately may lead to long-term treatments, which are discussed in Chapter 6. Wang et
al reported a detailed analysis of complications and
mortality associated with cervical spine surgery in
the United States in 2007.
Wang et al 63 found that complications increased
with the age of the patient, posterior fusion,
surgery related to cervical spondylosis and other
spinal degenerative diseases, and combined
anterior/posterior procedures.
63
Short-term effects were seen in almost all of the
932,000 patients whose hospital discharge records
were reviewed by Wang et al.
63
The highest morbidity and mortality were found immediately following
posterior procedures. Dysphagia was the most com-
Role of the Speech-Language Pathologist
1. SLPs working with patients following ACSS
must be aware that certain postural adjustments like the chin-tuck maneuver or turning
the head to one side to facilitate a swallow
may not be possible.
2. Review the operative report and x-rays, if
available, to know what postures or maneuvers must be avoided.
3. If the patient is in the hospital, a sign indi-
cating the patient should have only liquids
should be placed prominently above the bed.
4. Family members should be aware that
bringing food and liquid to a hospitalized
patient should be cleared with the hospital
medical staff.
5. For patients seen in an outpatient clinic, the
SLP should be aware of the patient’s history
and current medical status before beginning
any dysphagia exercises.
94 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
Treatment Tips Following Anterior
Cervical Spine Surgery
Transit — oral cavity to pharynx (CN IX, CN X,
CN XII)
Transit — pharynx to esophagus (CN X, CN XII)
1. Before the surgery, the patient should have
plenty of soft and pureed foods (see IDDSI
DIET, Chapter 8).
2. Have the patient swallow pills one at a time.
Swallowing with a thickened liquid may be
easier.
3. Do not throw the head back when swallowing
pills.
4. Use bendable straws, and keep the head
relaxed with the chin parallel to the floor. Do
not tilt the head back or tip it forward in a
chin-tuck position.
5. Avoid crushing medications—that may change
the way the medication is supposed to work
or improperly interact with other medications.
6. If the patient feels pain in the back or shoul-
ders, a heating pad may be helpful. If the
pain persists, the patient should return to the
surgeon for consultation.
SUMMARY
The phases of swallowing along with the critical
cranial nerve involvement at these phases are summarized here.
Oral Phase
Retention and mastication — retention of the
bolus in the mouth (CN VII)
Sensation — feel, taste, temperature (CN VII,
CNIX)
Esophageal Phase
Sensation — perception of bolus at or below the
CPM (CN X)
Transit — to lower esophagus (CN X)
Reverse transit (regurgitation) — UES and LES
pressure irregularities
The conditions and diseases encountered by
the members of the swallowing rehabilitation team
extend from occasional coughing or choking while
eating and extend to obvious debilitating diseases
such as esophageal cancer or Parkinson disease. The
clinician should not be fooled, however, into thinking that a patient complaining of occasional choking
does not have a significant swallowing disorder or
a disease or disorder that is being reflected in its
early stages. In this chapter, conditions and diseases
that give rise to swallowing disorders or that foretell
future dysphagia are reviewed. It should be pointed
out that causal relationships are not the hallmark
of many swallowing disorders. Rather, the swallowing disorder may develop shortly after the disease
or disorder or may develop long after a condition,
such as a swallowing disorder years after radiation
therapy to the larynx or pharynx. The astute clinician, regardless of their medical or paramedical
specialty, should work as a team member with other
clinicians who are also treating the patient. In some
cases, this may be the general practitioner, whereas
in other cases, the team may include an entire surgical or neurological group.
Salivation — needed to form the bolus (CN VII,
CN IX)
Oral and lingual transit — cranial nerves operating motorically (CN X, CN XII)
Pharyngeal Phase
Sensation — perception of bolus at posterior
pharyngeal wall (CN IX)
DISCUSSION QUESTIONS
1. Discuss the possible complications of treat-
ing a patient with a swallowing disorder
who has (a) advanced Parkinson disease or
(b)advanced ALS. What are some of the
differences in these patients that affect
treatment?
3. SWALLOWING DISORDERS ARISING FROM NEUROLOGICAL DISORDERS AND OTHER DISEASES 95
2. The current literature on reflux disease
suggests that both GERD and LPRD may
contribute to swallowing disorders. Why is
it important for the SLP to understand the
importance of GERD and LPRD as they relate
to the treatment of swallowing disorders?
See, for example, Fletcher KC, Goutte
M, Slaughter JC, Garrett CG, Vaezi MF.
Significance and degree of reflux in patients
with primary extraesophageal symptoms.
Laryngoscope. 2011;121(12):2561–2565; and
Altman KW, Prufer N, Vaezi MF. The challenge
of protocols for reflux disease: a review and
development of a critical pathway. Otolaryngol
Head Neck Surg. 2011;145(1):7–14 or Milan
MR, Belafsky PC. Cough and swallowing
dysfunction. Otolaryngol Clin North Am.
2010;43(1):35–42.
3. Describe how you would change the plan
of treatment for a patient who was recently
diagnosed with mild Parkinson disease and
who was told that his problems might get
worse over time. How often would you see
the patient? What types of therapy would you
recommend at each visit?
STUDY QUESTIONS
D. Is associated with cervical spine surgery in
older adults
E. Is diagnosed with a modified barium
swallow or fiberoptic endoscopic
evaluation of swallowing test (FEEST)
3. The swallowing problems associated with
CVAs
A. Usually end shortly after the acute period
has passed
B. May occur during the first 24 hours after a
CVA or may develop weeks or even months
after the occurrence
C. Are generally not life threatening if the
CVA is on the right side of the brain
D. Are primarily dangerous if the patient is
also an older adult
4. Autoimmune disorders of swallowing are
generally due to
A. Obstruction along the passageway of food
or liquid
B. Inflammation within the esophagus causing
regurgitation or choking
C. Inadequate lubrication for the normal
passage of food or liquid from the
oropharynx to the hypopharynx
D. All of the above
1. Aspiration occurs when
A. Food or liquid remains at the entrance to
the laryngeal inlet
B. Food or liquid is regurgitated up from the
esophagus into the oral cavity
C. Food or liquid enters the airway below the
vocal folds
D. The patient coughs following drinking or
eating
2. Aspiration pneumonia
A. Is a swallowing disorder resulting from
food or liquid residing in the trachea or
lungs
B. Is a condition of older adults who recently
had a CVA and continued to be fed
C. Is continued oral without assessment of the
patient’s swallowing status
5. GERD and LPRD are
A. Inflammatory disorders of the lower
esophagus
B. Inflammatory disorders of the esophagus
that affect structures within and above the
esophagus
C. Not true swallowing disorders because
they rarely cause aspiration or aspiration
pneumonia
D. Usually exist in patients with dysphagia but
rarely require specialized treatment
6. Recurring concussions that ultimately result
in depression, anger, or unexplained violent
behavior are considered
A. Normal for older adults
B. Evidence of CTE
C. A diagnostic basis for muscular dystrophy
D. Evidence of a brainstem stroke
96 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
7. Dysphagia after cervical spine surgery is
A. Common in the early postoperative period
B. Often self-limited
C. Often due to injury to the recurrent
laryngeal nerve
D. All of the above
8. Dysphagia after cervical spine surgery is
due to
A. Scarring of the retropharyngeal space
B. Edema
C. Disruption of the pharyngeal plexus
D. Pain
E. All of the above
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Swallowing Disorders
Following Head and
Neck Surgeries
CHAPTER OUTLINE
Introduction
Neoplasms
Exophytic Tumors
Head and Neck Surgery
Lip Surgery and Floor of the Mouth Surgery
Surgery of the Tongue
Palate Surgery
Prosthetic Management of the Oral Cavity
Mandibular Surgery
Surgery in the Oropharynx
Hypopharyngeal Surgery
Laryngeal Surgery
Vocal Fold Medialization
Vocal Fold Injection
Laryngeal Framework Surgery
Arytenoid Adduction and Arytenoid
Medialization
Skull Base Surgery
Tracheotomy
Airway Pressure Changes
Expiratory Speaking Valves
Laryngeal Elevation
Glottic Closure
Pharyngeal Transit With Tracheostomy
Swallowing Disorders Following Radiation Therapy
Zenker Diverticulum
Summary
Chapter
4
99
100 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
Discussion Questions
Study Questions
References
A Look at the Chapter
In this chapter, we look at the major conditions and diseases of the head and neck that
require surgery and that, in many cases, leave
the patient with a swallowing disability. The
clinician must be aware of these conditions
to avoid further injury to the surgical area. For
patients undergoing head and neck cancer
surgery, organs or parts of organs are removed
or altered and/or treated with radiation therapy
or chemotherapy. The need for prosthetic appliances will be covered following oral cancer
surgeries. Head and neck surgeries may affect
the ability to swallow normally. Some procedures
involve nerve damage as a result of treating the
disease; others may require adaptation due to
loss of muscle. Clinicians must know the surgical
changes and /or radiation effects that take place
in treating the diseases following surgery. In this
chapter, emphasis is on knowing the remaining
organs following surgery, understanding
how they affect speech and swallowing, and
appreciating the possible neurological changes
accompanying the surgery.
INTRODUCTION
Patients requiring surgery for treatment of diseases
and disorders in the region of the head and neck
and the esophagus often report dysphagia at the
first medical visit. The management of patients
with a diagnosis of head or neck cancer (HNC)
or other diseases that may impact their swallow-
ing requires an understanding of the surgical
procedures and their resultant outcomes. These outcomes may affect the patient’s speech, swallowing,
and even their physical appearance. Whether the
treatment for the disease is surgery, radiation therapy
or chemotherapy, organs, nerves, and other structures critical to swallowing will undergo changes
that affect swallowing. The speech pathologist along
with the otolaryngologist and other medical and
rehabilitation specialists form a team responsible
for the patient’s recovery and quality of life.
Patients will also experience a period of dysphagia varying in time in the perioperative and/or
postoperative recovery process. Raber-Durlacher et
1
al
reported that 28% of patients with HNC report
difficulty with swallowing at their first presenta-
1
tion.
With the findings of HNC in younger patients
and improved treatments, it is expected that dysphagia prevalence will increase in the future.
2
Dysphagia may be short term, requiring neither special
tests nor the implementation of diet modifications,
or long term due to severe nerve damage or tissue
destruction, requiring the involvement of the entire
dysphagia rehabilitation team. For all patients being
treated for a disease involving the organs of swallowing, even those who are deemed safe to swallow,
a clinical bedside assessment should be done and
documented once the HNC diagnosis is made. When
any one or more of the swallowing valves does not
work due to injury or improper innervation, swallowing will be affected. Surgery, radiation, or a combination of the two can lead to minor swallowing
difficulty or life-threatening aspiration. The finding
of a delayed swallow or the patient reporting difficulty swallowing certain foods or liquids should
be noted, and further evaluation should be planned.
A report of the clinical swallow evaluation should
be part of the initial visit and treatment planning
once the diagnosis is made. Despite the number of
patients with HNC who develop dysphagia before or
after treatment, there remains controversy regarding
referral to the speech-language pathologist (SLP)
and to the types of diagnostic tests and treatments
that should be afforded to the patient.
3
This chapter reviews the major swallowing
problems associated with cancers of the head and
neck regions.
4. SWALLOWING DISORDERS FOLLOWING HEAD AND NECK SURGERIES 101
NEOPLASMS
Neoplasia are abnormal growths of tissues. They
can be malignant or benign; they are often referred
to as tumors when discussing them with a patient.
Tumors in the head and neck can cause distortion,
obstruction, reduced mobility, or neuromuscular
and sensory dysfunction of the passageways in the
upper aerodigestive tract and can affect swallowing
at any place along the way.
Consider the act of swallowing as a bolus passing through a series of valves. The valves in this
order are as follows:
Lip closure
Anterior tongue
Posterior tongue
Palate
Velopharyngeal contact
Larynx
Cricopharyngeal sphincter
Each valve can be the sole basis of the swallowing
problem, or the valves may fail to interact appropriately or timely to cause the problem.
Exophytic Tumors
Exophytic tumors interfere with swallowing principally by distorting or obstructing the aerodigestive
tract. Tumors with an infiltrating growth pattern may
cause reduced mobility or fixation of the tongue, soft
palate, pharynx, or larynx. Extrinsic tumors may lead
to obstruction or fixation and with that may impinge
on various cranial nerves. Intrinsic tumors are primarily compressive; however, they may also lead to
disruption of the swallow by restricting bolus flow.
Table 4–1 lists the common physiological changes
that occur following intrinsic and extrinsic tumors.
Tumors also affect swallowing by interfering
with the afferent fibers (sensory input) from the
mucosa of the upper aerodigestive tract by invasion
and destruction of the mucosal nerve endings, or
sensory nerves such as the trigeminal (V), glosso-
TABLE 4–1. Pathophysiology of Swallowing in Accordance
With Tumor Origin and Growth Pattern
Tumor Swallowing Pathophysiology
Intrinsic tumor
Exophytic growth Obstruction
Distortion
Anesthesia/hypesthesia
Infiltrating growth Fixation
Pain
Trismus
Cranial nerve deficits
Extrinsic tumor
Compression
Cranial nerve deficits
Fixation
pharyngeal (IX), and vagus (X) cranial nerves and
their branches.
Neoplasms of the floor of the mouth, tongue, or
buccal mucosa may by mass effect or by restricting
mobility of the tongue and floor of the mouth impair
a patient’s ability to interpose food between the
teeth. Tumor invasion of the dorsum of the tongue
or involvement of the lingual nerve (CN V) may affect
sensory input causing premature spillage of the bolus
into the pharynx and, consequently, aspiration.
Tumors of the pharynx may cause an adynamic
segment that interferes with peristalsis or laryngeal
elevation or may cause mechanical obstruction.
Tumors invading or destroying the larynx may cause
either an incompetent laryngeal sphincter or sensory denervation of the larynx.
Role of the Speech-Language Pathologist
The SLP should review the initial evaluation and
the operative report and obtain a comprehensive
case history from the patient. Treatment should
be based on findings from the clinical swallow
examination and from instrumental findings. More
details about the treatment are found in Chapter 7.