DISTURBANCE OF SWALLOWING AFTER TRACHEOSTOMY

954

DISTURBANCE OF SWALLOWING AFTER TRACHEOSTOMY S. A. FELDMAN M.B., B.Sc. Lond.,

M.B.

C. W. DEAL Sydney, F.R.C.S., F.R.C.S.E.

F.F.A.R.C.S.

SENIOR REGISTRAR, CARDIOTHORACIC UNIT*

CONSULTANT ANÆSTHETIST

W.

URQUHART

M.B. Edin., F.F.A. R.C.S. SENIOR

REGISTRAR, DEPARTMENT OF

WESTMINSTER

HOSPITAL,

RADIOLOGY†

LONDON

S.W.1

MOST patients with a tracheostomy can swallow food and fluids normally, but sometimes, when a cuffed tracheostomy tube has been inserted, they complain of difficulty in swallowing (Robbie and Feldman 1963). We describe here 3 patients who had a disordered swallowing-reflex after tracheostomy. The disorder resulted in food and fluid entering the larynx and producing tracheal soiling. X-ray studies of the swallowing reflex showed that the disorder resembled in its effects the results of bulbar paralysis although no neurological deficit was present. In all 3 patients the trachea was dilated: this may have been caused by the accumulation of aspirated fluid and food above the cuff of the tracheostomy tube producing tracheomalacia and dilatation.

Case-reports

Case 1 This patient had had

severe chronic bronchitis for many the occasion in question his admission had been precipitated by the development of bronchopneumonia. He was admitted in respiratory failure which became worse in spite of medical treatment and necessitated artificial ventilation through an anterior tracheal-flap tracheostomy. He made excellent progress initially but complained of difficulty in swallowing fluids. Increasing volumes of air were required in the cuff of his tracheostomy in order to obtain an air-tight seal between the cuff and tracheal wall. A new tracheostomy tube was inserted and 15 c.cm. of air were required to inflate the cuff sufficiently to prevent a leak of air. In spite of this enormously distended cuff, aspiration of the trachea showed the presence of food in the tracheobronchial tree. It was thought that a tracheooesophageal fistula had developed, and a barium swallow was performed. The barium entered both the oesophagus and the trachea, which was grossly distended (fig. 1). The cuffed tracheostomy tube was replaced with an uncuffed silver tube and the patient was fed through a nasogastric tube. The patient was weaned off the ventilator with the assistance of a nikethamide drip. Two weeks later a repeat barium swallow showed a persistence of the swallowing disorder but this was now less striking. The dilatation of the trachea was also diminishing.

years and

on

Fig. 1-A tracheogram produced by aspiration of barium during a barium swallow, showing the grossly dilated trachea.

Case 2 A man with chronic bronchitis had a triple cardiac-valve replacement with a Starr-Edward’s prosthesis. An anterior tracheal-flap tracheostomy was performed and he was ventilated artificially for ten days postoperatively. After this he became reluctant to swallow and complained that " the food went down the wrong way." Tracheal ballooning was evident, 20 c.cm. of air were needed to inflate the cuff of a no. 11 James tracheostomy tube to produce complete occlusion of the trachea. On release of the cuff, food and saliva dammed above the cuff entered his lower trachea necessitating a careful bronchial toilet. A silver tube with a speaking-flap was introduced and the patient supported with intravenous therapy. Three days later he had a cardiac arrest and died. At necropsy the trachea was found to be dilated with extensive mucosal erosion at the level of the cuff and in the trachea above. His lungs showed pneumonic changes consistent with repeated aspiration.

grossly

Case 3 This patient had a leaking abdominal aortic aneurysm resected and grafted. He had had chronic bronchitis for many years. Postoperatively, his respiration was inadequate and he was artificially ventilated through a cuffed endotracheal tube. The next day an anterior tracheal-flap tracheostomy was performed and a James tracheostomy introduced. Recurrent chest-infections made weaning from the respirator difficult. * C. W. D. at present holds a fellowship at the University of California. After three weeks his spontaneous respiration was considered &dag er; Present appointment: consultant, Newcastle General Hospital. adequate and he was weaned trom the respirator. 1 he James tracheostomy tube was replaced by a silver tube. Subsequently, he began to aspirate fluids and developed bronchopneumonia. The silver tube was replaced by a no. 12 James tube and the cuff inflated. A cinefilm of ’Gastrografin’ swallow at this time showed gross tracheal aspiration. Figs. 2 and 3 show the ease with which the gastrografin entered the larynx, the absence of normal laryngeal elevation, and the absence of a glottic reflex. The trachea became dilated as judged by the amount of air needed to produce occlusion by the tracheostomy cuff. This increased from 9 to 16 c.cm. Although the patient was fed through a gastric tube, the aspiration became progressively more serious, causing Fig. 2-A frame from a cinefilm of a gastrografin swallow. The disorder pulmonary collapse and bronchopneumonia. Since of swallowing has produced massive tracheal aspiration. he could not tolerate being nursed while being held Fig. 3-Drawing showing the main features of fig. 2: epiglottis (A); laryngeal down for more than five minutes, a simple laryaventricle (B); and tracheostomy tube (C).

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955

performed as a life-saving procedure. Posthe operatively did well and for three weeks had no further chest infection and was able to eat normally. Unfortunately, three weeks after the laryngectomy, when he was preparing for convalescence, he collapsed unexpectedly and died. Discussion There seem to be three possible explanations of a disgectomy

was

order of swallowing produced by the tracheostomy:

(1) Desensitation of the larynx resulting from the diversion of the normal air current through the tracheostomy. (2) Fixation of the larynx by the tracheostomy, especially with an anterior tracheal flap (Bjork 1960). This might prevent normal elevation of the larynx which is essential for coordinated swallowing. (3) Compression of the oesophagus by the cuff in the trachea. The X-rays suggest that there is an incoordination of the swallowing-mechanism rather than a passive obstruction at the cuff level, which favours the first or second explanations. All 3 patients had chronic bronchitis. Tracheal ballooning during coughing can be associated with the tracheomalacia that may develop in chronic bronchitis. The rapidity with which the trachea dilated after the insertion of a cuffed tracheostomy tube and the inflammation of the mucosa above the tracheostomy seen at necropsy in case 2 suggest that the tracheal ballooning in these patients was secondary to the aspiration. Aspirated saliva and food probably accumulated above the tracheal cuff, causing stagnation and infection which led to the tracheomalacia. The weakened tracheal wall was then distended by the tracheal cuff. Conclusion and Summary 3 patients had a loss of the normal mechanism of swallowing after an anterior tracheal-flap tracheostomy and the use of a rubber, cuffed tracheostomy tube. This defect may have resulted from a desensitisation of the larynx after a diversion of the air-passage or a fixation of the larynx by the tracheostomy. Tracheal ballooning with which it was associated is considered to be secondary to the aspiration. The 3 patients who had overt aspiration of food and fluid as a complication were in a series of 328 patients in whom this procedure had been undertaken. Many patients who are reluctant to swallow after tracheostomy may, however, be developing this condition, and an effort should then be made to allow some air to be directed through the larynx. Cuff inflation should be reduced to a minimum. Once the condition is fully developed it is very difficult to treat and in spite of intravenous or gastric-tube feeding, saliva may be aspirated. If all else fails, simple laryngectomy may be necessary to save the patient from the effects of repeated tracheal aspiration. We thank Mr. C. Drew and Mr. G. Westbury for permission to describe cases 2 and 3. Fig. 1 first appeared in the British Journal of Ancesthesia.

Requests for reprints should be addressed to Dr. S. A. Feldman, Department of Anaesthetics, Westminster Hospital, St. John’s Gardens,

London S.W.I. REFERENCES

Bjork, V. O. (1960) J. thorac. cardiovasc. Surg. 39, 179. Robbie, D. S., Feldman, S. A. (1963) Br. J. Anœsth. 35, "

771.

The discussion concerning the use of the courtesy title doctor for dental surgeons comes up periodically In view of the scope of dentistry today, for dentists to use the title might be just and it might help to improve our standing with our patients, but without doubt the general public forms its opinion of its dentists mainly according to its experience when seeking and receiving treatment-the profession has as many public relations officers as there are practitioners. Before deciding on this matter of title ourselves it might, perhaps, be a good idea to discover what our patients think about it."-British Dental Journal, April 19, 1966. ...

PROGRESSION OF RETROPERITONEAL FIBROSIS DESPITE CESSATION OF TREATMENT WITH METHYSERGIDE FRANKLIN D. SCHWARTZ M.D.

Maryland

ASSISTANT PROFESSOR OF MEDICINE, UNIVERSITY OF ILLINOIS COLLEGE OF MEDICINE, AND ASSISTANT ATTENDING PHYSICIAN, PRESBYTERIAN-ST. LUKE’S HOSPITAL, CHICAGO

M.B. RESEARCH

GEORGE DUNEA Sydney, M.R.C.P., M.R.C.P.E.

FELLOW, UNIVERSITY OF ILLINOIS COLLEGE

OF MEDICINE AND PRESBYTERIAN-ST.

HOSPITAL,

LUKE’S

CHICAGO

METHYSERGIDE

C’ Sansert’,Deseril’) an effective agent prophylactic treatment of migraine, seems to be causally related to the development of retroperitoneal fibrosis (Lancet 1965, Graham 1966 et al.)-the process regresses spontaneously after the drug is withdrawn and early surgical intervention is usually unnecessary. We describe here a patient in whom retroperitoneal fibrosis continued to progress over a period of six months after the administration of methysergide was stopped. in the

Case-report A 59-year-old white man was admitted in November, 1964, for evaluation of hypertension. He had been in good health

Fig. 1-Intravenous pyelogram showing mild calyectasis is seen on the left.

a

contracted

right kidney;

until six months previously when he had increasing weakness, tiredness, and nocturia. Vomiting, dizziness, and swelling of the legs and abdomen were first noted six weeks before admission. Hypertension was recorded for the first time two weeks before admission. He had gained 17 lb. (8 kg.) in weight. There was no decrease in urine output. Occasional lower back pain had been noted for about one year. He had had migraine for about thirty years and had been treated with methysergide, 2-8 mg. per day for three years, but the drug had been discontinued several weeks earlier. Physical examination revealed an alert elderly man. The blood-pressure (B.P.) was 190/110 mm. Hg. The optic fundi were normal. Slight cardiac enlargement, peripheral oedema, and a trace of ascites were noted. No epigastric bruit was heard. The haemoglobin was 12-5 g. per 100 ml.; blood-urea-nitrogen (B.U.N.) was 172 mg. per 100 ml.; serum-creatinine 19-7 mg.

ml.; serum-potassium 6-9 mEq. per litre; serumbicarbonate 17-1 mEq. per litre. After four days of bed-rest the B.P. had fallen to 140/80 mm. Hg and spontaneous diuresis ensued. The B.U.N. fell to 15 mg. per 100 ml. and serum-creatinine to 1-5 mg. per 100 ml. A small right kidney with poor function and mild calyectasis

per 100