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.