Differential diagnosis, investigations and treatment
In the new hospital ward nursing screening test for dysphagia and
specific evaluation of swallowing performed by speech and language
pathologist (SLP) were carried out, as it is usually performed on
tracheotomy patients at the beginning of the recovery. The tracheotomy
tube was in place, the patient breathed in ambient air, using
fenestrated inner cannula with decannulation plug. Evaluation of
secretion management, Evan’s Blue dye test, test with gel-water and
methylene blue were negative. For preventive purposes, however, a pureed
diet was recommended. In addition, evaluation during lunch was performed
in order to detect any signs or symptoms of dysphagia: at the end of the
meal, some traces of bolus in the aspirate were found in association to
wet voice. That same evening, while taking dinner with pureed diet under
supervision, the presence of food material in the tracheal tube without
reflex cough and desaturation (pulse oximeter readings from 99% to
94%) were observed. The meal was interrupted and the material was
aspirated with rapid recovery of oxygen saturation. Subsequently, after
the placement of the decannulation plug, wet voice was noticed. Since
similar findings were also obtained by the SLP in the following days
during daily evaluation at meal, oral feeding was interrupted due to the
high risk of pulmonary complications. For this reason, on
25th May, after an unsuccessful attempt to place
nasogastric tube, the medical team decided to feed the patient with
parenteral nutrition. On 1st June gastroscopy was
performed to exclude mechanical obstructions but it showed no notable
alterations. On 3rd June the patient underwent FEES,
which revealed a complete paresis of the right hemilarynx and a partial
paresis of the left hemilarynx, in absence of heteroproductive lesions.
The right paretic vocal fold was in paramedian position, the left vocal
fold, with partial paresis, was in median position. There was sufficient
breathing space. Swallowing was characterized by vallecular and
retrocricoid salivary stagnation. A similar situation occurred during
spoon-thickened liquid swallowing test with stagnation and late
inhalation. Reduced laryngeal sensibility and late and poor reflex cough
were also observed. On 5th June the patient underwent
head and neck CT scan to detect the possible causes of the vocal folds
paresis. The CT scan showed a structural inhomogeneity just above the
cricoarytenoid joints, sclerosis of the upper portion of the cricoid and
of both arytenoids. The Radiologist reported that the alteration
described was not purely characteristic for neoplasia, but more
correlated to a chronic inflammatory event. For this reason steroid
therapy was introduced using intravenous methylprednisolone 20 mg twice
a day for 15 days, followed by methylprednisolone 20 mg/day for a
further 25 days. After FEES and CT, the medical team considered
appropriate to position PEG (on 10th June). The
patient underwent one-hour speech therapy re-education sessions from
Monday to Friday, with the following objectives: prevention of arytenoid
ankylosis, improvement of glottic closure, strengthening of the basis of
the tongue. FEES, on 13th July, showed a clear
improvement of glottic muscle: the right hemilarynx paresis remained but
the left hemilarynx had a normal motility. Salivary stagnation was not
present. Swallowing tests were normal with all consistencies. Therefore,
it was indicated to start an oral nutrition re-education, under
supervision of a SLP. The patient started nutrition per os with pureed
diet and spoon-thickened liquid and constant training for compensatory
posture under the SLP supervision. Daily calories requirement was
guaranteed by lunch per os and two other meals by PEG. Administration of
drug therapies was by PEG. The patient’s weight was measured daily. The
oral intake was gradually increased and solid foods and liquids were
introduced. On 16th July there was no more secretion
or need to aspirate the patient, so tracheostomy tube was removed.