Discussion
Since the beginning of the 2020, about 130 others patients with Covid-19 have been hospitalized in our Rehabilitation Unit. Among them, 17 were diagnosed with mild dysphagia, with a fast recovery. None of them needed enteral nutrition or prolonged speech therapy. Due to the severe respiratory failure, they also had a prolonged intubation, a tracheotomy (but for a maximum of one month) and were affected by a Critical Illness Myopathy and Neuropathy, but they did not develop a severe dysphagia. The patient of this case report was the only one who was still carrying the tracheotomy tube on his arrival and had to keep the tracheal tube because of abundant secretions in the airways, which were probably a result of many factors: the previous history of COPD, the recent pneumonia and the irritation of the airways due to inhalation.
This late inhalation was challenging to identify because the quality of the voice was already altered by the presence of the tracheotomy (despite the decannulation plug). Moreover, his voice was euphonic, not breathy and he breathed well in ambient air with the decannulation plug. It is already known that vocal fold paresis is often misdiagnosed especially if the symptoms are non-specific [8]. For these reasons it was difficult to guess a vocal fold paresis.
As it is documented in literature, swallowing with tracheotomy is more difficult due to reduced sensitivity stimulation, attenuated tracheal reflexes, inability to generate adequate under-glottal pressure and reduced reflex cough. However, the presence of the tracheal tube has allowed us to directly establish inhalation since during these episodes there was not reflex cough as a result of a reduced laryngeal sensibility. These issues were confirmed by FEES, which was performed after observing the patient’s performance at meal for several days. According to the ESSD commentary, the instrumental assessment has not been previously performed because of high infection risk [5].