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Dysphagia Following Posterior Fossa Surgery in Adults
Peer-Review Reports
Dysphagia Following Posterior Fossa Surgery in Adults Rishi Wadhwa1, Jamie Toms1, Prashant Chittiboina1, Tamir Tawfik1, Chad Glenn1, Gloria Caldito2, Bharat Guthikonda1, Anil Nanda1
Key words Aspiration - Dysphagia - Enteral tube - Posterior fossa -
Abbreviations and Acronyms EFD: Enteral feeding at discharge MLR: Multiple logistic regression PEG: Percutaneous endoscopic gastrostomy p-fossa: Posterior fossa
- OBJECTIVE:
Our study seeks to assess the incidence of aspiration and prolonged dysphagia needing enteral feeding at discharge (EFD) in adults after posterior fossa (p-fossa) surgery.
- METHODS:
A retrospective review was done on 56 patients with p-fossa surgery who needed a swallowing evaluation postoperatively. Questionnaires were sent to patients with EFD. Using univariate and multiple logistic regression analysis, risk factors for aspiration, EFD, and continued enteral feeds were identified.
- RESULTS:
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Most patients were male and had p-fossa tumors. Multiple swallowing evaluations were needed in 25 (45%) patients. Aspiration was seen in 23 (41%) and 16 (27%) had EFD. Older age and number of evaluations were significantly associated with both aspiration and EFD (P < 0.05). Lateral approach was significantly associated with EFD (P [ 0.047). In addition, multiple logistic regression identified aspiration as an independent significant predictor for EFD (P < 0.01). Mean operative time and tumor location did not have a significant correlation with EFD. At mean follow-up (15 months), only 5/16 needed continued enteral feeds.
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- CONCLUSION:
From the Departments of 1Neurosurgery and 2 Biometry, Louisiana State University Health Sciences Center, Shreveport, Shreveport, Louisiana, USA To whom correspondence should be addressed: Anil Nanda, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2013.01.035 Journal homepage: www.WORLDNEUROSURGERY.org
INTRODUCTION The posterior fossa (p-fossa) is an area including the brain regions and cranial nerves below the tentorium (8). These regions not only are crucial in wakefulness, speech, swallowing, hearing, facial sensation and musculature, and tongue movement, but they are also a common site for many types of tumors, vascular lesions, infection, and congenital abnormalities. Many of these lesions require surgical management (2, 6), and many complications can occur because of crowding of this small space by critical structures. As a result, patients undergoing p-fossa surgery may present with postoperative hydrocephalus, vertigo, deafness, facial numbness or weakness, tongue numbness or weakness, dysphonia, mutism, and dysphagia (1, 2, 4, 6, 8). A known complication after p-fossa surgery is swallowing dysfunction, or dysphagia (10). Physiologically, swallowing is generally characterized by four stages: an oral preparatory stage, an oral stage, a pharyngeal stage, and an
Although 27% patients had EFD after p-fossa surgery, only 5/56 (9%) required continued enteral feeding. Aspiration, age, and lateral surgical approach is associated with EFD. In patients who demonstrate aspiration, we recommend placement of enteral feeding tube. Although most will not require continued enteral feeding at follow-up, longer follow-ups are needed.
esophageal stage (3, 5, 11). In the event that any these four stages fail, a bolus cannot pass normally from the oral cavity to the stomach and this condition is termed dysphagia (5). Dysphagia can also occur because of decreased neurologic status as well as impairment of the anatomic structures from the brainstem nuclei to the laryngeal muscles. This may result in disrupted initiation, coordination, or maintenance of swallowing. Common deficits that are present with dysphagia are abnormal tongue movement, poor jaw stability, inefficient chewing, impaired lip seal, multiple swallows to clear a bolus, and lack of awareness of dysphagia (7). Any of these deficits can lead to nutritional deficits, emotional and social disruption, a need for supplementary feeding, and life-threatening aspiration (7, 8, 11).
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Aspiration can lead to significant problems including pneumonia (7, 8), which is a major cause of mortality in children undergoing p-fossa surgery (9). It is imperative to detect aspiration quickly to prevent such disastrous outcomes (10). There are several studies that assess swallowing in children after p-fossa surgery, but to our knowledge there are no reported evaluations of postoperative swallowing function in adults. Our study seeks to assess the incidence of aspiration and dysphagia and subsequent outcomes in adults that have undergone p-fossa surgery. METHODS A retrospective review was conducted on all patients undergoing p-fossa surgery from July 2007 until September 2010, excluding those cases of neurovascular
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decompression in trigeminal neuralgia, after approval from the institutional review board. Data on 56 patients who had p-fossa surgery at the LSUHSC-Shreveport over a 3-year period was analyzed to evaluate swallowing function following surgery and determine risk factors for postoperative aspiration and dysphagia. For those patients that were manifesting aspiration and/or dysphagia, further analysis was performed to evaluate the number and type of swallowing evaluations as well as status of swallowing function at discharge. A certified speech/language pathologist did bedside swallowing evaluations if patients deemed to be at any risk for aspiration or dysphagia by the neurosurgical team and/or nursing staff. Clinical findings that warranted further evaluation included having the patient swallow water and observing for the presence of breathlessness, wet hoarseness, or coughing. Evaluations were sometimes performed multiple times to account for improvement in postoperative examination. Barium swallow studies were done if bedside evaluation was not adequate or if aspiration was exhibited by the patient. “Silent” aspiration was radiologically confirmed with x-ray demonstration of contrast material passing through the vocal cords into the larynx. Enteral feeding tubes were placed 10e14 days postoperatively in those patients with enteral feeding at discharge (EFD). Patients who continued to demonstrate swallowing dysfunction at discharge were identified for further follow-up. Association was sought between two main outcomes— postoperative aspiration and EFD from hospital. We chose EFD as an intermediate outcome measure of swallowing function, with the need for prolonged enteral feeding as a final outcome measure. Sixteen patients failed their last swallow evaluation before discharge and were discharged with EFD. These patients were followed postdischarge and evaluated for dysphagia and long-term feeding through enteral tubes with follow-up questionnaires administered to the patients or their immediate caretakers. Statistical Techniques Chi-square or Fisher test were used to evaluate the association between outcome measures and categorical variables. Wilcoxon rank-sum test was used to compare
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continuous variables such as age and number of swallowing studies and also used to compare average follow-up time and discomfort level between patients with and without continued enteral feeding. Next, multiple logistic regression analysis was used to determine independent significant factors for swallowing dysfunction. Correlation between aspiration and dysphagia was determined along with EFD. The duration of extended enteral feeding for those with EFD was determined and additionally, sex, pathology type, location of tumor, operative time, preoperative dysphagia, difficulties with speech and tongue movements, and level of discomfort were all evaluated for this group.
Table 1. Summary Statistics on Patient Characteristics and Outcomes and Factors Significantly Associated with Aspiration and Dysphagia (N ¼ 56) Characteristic/ Outcome Male
32 (57.1)
Female
24 (42.9)
Pathology Abscess
1 (1.8)
Vascular
17 (30.4)
Congenital Tumor
Data on 56 patients who had p-fossa surgery at the LSUHSC-Shreveport over a 3-year period (2007e2010) were analyzed to evaluate swallowing function following surgery and determine risk factors for postoperative aspiration and dysphagia. Of the 56 patients with p-fossa surgery and swallowing evaluations, 25 patients had multiple tests and there were a total of 92 swallowing evaluations (Table 1). The majority of the patients were male (57.1%) and most had p-fossa tumors as the primary pathology (62.5%). Postoperatively, 23 (41.1%) aspirated at least once during hospital stay and 16 (28.6%) had EFD. The same factors appeared to contribute to both the incidence of aspiration and EFD, namely, age, number of evaluations, result of last swallow evaluation, and having barium for last study. A lateral sub-occipital surgical approach was significantly associated with EFD (P ¼ 0.047) but not with aspiration (P ¼ 0.09). In our study, EFD was significantly associated with aspiration and vice versa; the corollary being that there was significant correlation between incidence of aspiration during hospitalization and the need for EFD. Significantly higher proportions of patients with aspiration were observed among those with barium swallow study as their last swallow study prior to discharge (82.4%), and those who had multiple swallow evaluations postoperatively (88%). Significantly, the patients who demonstrated aspiration during the postoperative phase formed a much
2 (3.6) 35 (62.5)
Stroke
RESULTS
Number (%) or Mean SD, Median, Range
1 (1.8)
Multiple swallow evaluations*y
25 (44.6)
Enteral feeding at discharge (EFD)*
16 (28.6)
Aspirationy
23 (41.1)
Last swallow study was Barium*y
17 (20.4)
Location along brainstemeponsemedullary axis Intraparenchymal
7 (12.5)
Lower
25 (44.6)
Upper
21 (37.5)
Upper/lower
3 (5.4)
Approachy Lateral
34 (60.7)
Midline
22 (39.3) y
Age (years)*
49.3 17.5, 51.0, 8e81
Number of evaluations*y
1.6 1.1, 1.0, 1e8
Operative time (minutes)
285.6 156.1, 237.5, 45e724
*Significantly associated with aspiration during hospitalization. ySignificantly associated with enteral feeding at discharge (or EFD).
higher proportion of those with EFD (93.8%) than those without EFD (20%) (P < 0.01) (Table 2). A higher proportion of patients with EFD were also observed in those with barium as their last swallow study (58.8%), and those needing multiple swallow evaluations (56.0%). Surgical approach to the p-fossa also significantly affected the occurrence of EFD, with the
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Table 2. Factors Significantly Associated with Aspiration During Hospitalization and EFD Proportion with Aspiration, Number (%)
Factor/Categories
P Value
Hospitalization <0.01
EFD No (n ¼ 40)
8 (20.0)
Yes (n ¼ 16)
15 (93.8) <0.01
Barium swallow study Yes (n ¼ 17)
14 (82.4)
No (n ¼ 39)
9 (23.1) <0.01
Number of evaluations Multiple (n ¼ 25)
22 (88.0)
Single (n ¼ 31)
1 (3.2) Proportion with Dysphagia, n (%)
EFD <0.01
Aspiration at least once during hospitalization Yes (n ¼ 23)
15 (65.2)
No (n ¼ 33)
1 (3.0) <0.01
Barium swallow study Yes (n ¼ 17)
10 (58.8)
No (n ¼ 39)
6 (15.4) <0.01
Number of swallow evaluations Multiple (n ¼ 25)
14 (56.0)
Single (n ¼ 31)
2 (6.4)
Surgical approach
0.047
Lateral (n ¼ 34)
13 (38.2)
Midline (n ¼ 22)
3 (13.6)
EFD, enteral feeding at discharge.
Table 3. Factors Significantly Associated with Postoperative Aspiration and EFD, Mean SD, Median, Range Factor
Had Aspiration (n [ 23)
No Aspiration (n [ 33)
56.4 16.4, 58.0, 19e81
44.3 16.6, 46.0, 8e70
P Value
Postoperative aspiration Age Number of swallow studies
2.3 1.3, 2.0, 1e8
1.2 0.6, 1.0, 1e4
Had Dysphagia (n [ 16)
No Dysphagia (n [ 40)
60.1 16.0, 60.5, 19e81
45.0 16.3, 49.0, 8e70
0.01 <0.01
EFD Age Number of swallowing studies
2.4 1.6, 2.0, 1e8
EFD, enteral feeding at discharge.
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1.4 0.7, 1.0, 1e4
<0.01 <0.01
lateral approach causing a significantly higher proportion of patients (38.2%) with EFD versus the midline approach (13.6%) (P ¼ 0.47) (Table 2). Using the Wilcoxon’s rank-sum test, we found that a higher age and an increasing number of swallow evaluations were associated with both the incidence of aspiration and with EFD (Table 3). Multiple logistic regression analysis identified the number of swallowing evaluations as an independent predictor of postoperative aspiration. Likewise, result of multiple logistic regression analysis identifies aspiration as the only independent significant predictor for EFD (Table 4). Adjusted for the effects of other significant factors, odds for dysphagia among patients who aspirated during the postoperative period were 58.8 times the odds of patients who did not aspirate. Summary statistics for the 16 patients with EFD are shown in Table 5. Median follow-up time for these patients was 10 months (ranging from 1 to 38 months). At last follow-up, there were 5 (31.2%) patients still with percutaneous endoscopic gastrostomy (PEG); 10 (62.5%) had speech/ tongue problems, 6 (40%) had some form of discomfort associated with enteral feeding (discomfort level >0), and 4 (25%) patients had died. Four patients with postoperative dysphagia had swallowing problems before surgery attributed to their preoperative pathology. Among the 4 patients who had swallowing problems before surgery, 2 (50%) had continued PEG use at the last follow-up. Factors significantly associated with continued PEG use were a persistent difficulty in swallowing both solids and liquids. The proportion of patients with continued PEG use was higher among those with problems swallowing solids and liquids (55.6% for both). There were no significant differences in average follow-up time in months, days with swallow problem after surgery, and discomfort level between patients with and without continued feeding with PEG tube (Table 6). It can be noted that none of the significant factors for EFD and aspiration were significantly associated with continued dysphagia and PEG usage. The nonsignificant results are likely due to the small sample sizes for the two groups compared (5 and 11). Mean operative times between those with and without EFD were 287 and 284
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Table 4. Independent Significant Predictors of Postoperative Aspiration Predictor/Factor
OR
95% CI
P Value
16.7
2.8e98.4
<0.01
58.8
6.8e500.0
<0.01
Postoperative aspiration Number of swallowing studies EFD Aspiration EFD, enteral feeding at discharge; OR, odds ratio.
Table 5. Summary Statistics on Patients with EFD and Significant Factors for Continued PEG Use (N ¼ 16) Characteristic/Outcome
Number (%) or Mean SD, Median, Range
Male
9 (56.2)
Multiple swallow studies in hospital
14 (87.5)
Last study was barium swallow study
10 (62.5)
Continued PEG at last follow-up
5 (31.2)
Continued speech/tongue problem
10 (62.5)
Difficulty with swallowing solids*
9 (56.2)
Difficulty with swallowing liquids*
9 (56.2)
Discomfort level >0
6 (40.0)
Pathology Tumor
10 (62.5)
Vascular
6 (37.5)
Location of lesion along the brainstemeponsemedullary axis Intraparenchymal
1 (6.2)
Lower
8 (50.0)
Upper
5 (31.2)
Upper/Lower
2 (12.5)
Had aspiration (while in hospital)
15 (93.8)
Had swallow problem before surgery
3 (18.8)
Had swallow problem before surgery
16 (100.0)
Surgical approach Lateral
13 (81.2)
Midline
3 (18.8)
Died
4 (25.0) 49.5 182.1, 0, 0e730
Days with dysphagia before surgery Days with dysphagia after surgery
172.8 261.3, 90.0, 14e1085 60.1 16.0, 60.5, 19e81
Age (years)
2.4 1.6, 2.0, 1e8
Number of swallowing studies Operative time (minutes)
287.9 165.8, 235.0, 45e632 14.9 12.7, 10.0, 1e38
Follow-up time (months) after discharge EFD, enteral feeding at discharge; PEG, percutaneous endoscopic gastrostomy. *Significantly associated with continued dysphagia and PEG use.
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minutes (P ¼ 0.86), respectively (Table 7). The medulla was the location of pathology in 25 (44.6%) patients in the entire study group and 8 (50%) patients in the EFD group. The location of the lesion leading to p-fossa surgery was not significantly associated with EFD (P ¼ 0.42) (Table 8). Two of the patients with continued PEG use at last follow-up died. One patient died at 10 days postdischarge from cardiorespiratory failure and the other patient died at 60 days postdischarge from an unknown cause. Two other patients in the study expired. One passed away 24 days postoperation from a gastrointestinal bleed but who was no longer dependent on enteral feeding. The other had continued PEG use at the 5-month follow-up but had a complete resolution of postoperative dysphagia. The PEG was reinserted to manage their newly discovered pancreatic cancer (to which this patient succumbed during the study period). In the small sample size of patients with EFD (16 patients), no factors were observed to be significantly associated with death. Among patients with p-fossa surgery, aspiration and EFD were significantly correlated and were predictive of each other. Among those with EFD, problems with swallowing solids and liquids were significantly associated with continued dysphagia and PEG use. DISCUSSION Dysphagia, or swallowing dysfunction, is a devastating complication that can affect individuals after p-fossa surgery. This complication can lead to malnutrition and psychological consequences, as well as aspiration (8). Because of these lifealtering and fatal effects of swallowing dysfunction, it is imperative to accurately diagnose swallowing abnormalities after surgery (9). In a pediatric study by Morgan et al., 73% of patients who underwent pfossa tumor resection demonstrated dysphagia during the first 2 weeks of postoperative recovery (8). There are four stages of swallowing beginning with mastication and bolus formation as part of the oral preparatory stage. After the bolus has been formed in the first stage, the second stage utilizes the tongue and hard palate to transport the bolus to the posterior portion of the oral cavity; this is termed the oral stage (11). Following the
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Table 6. Comparisons Between Patients with and without Continued PEG Use, Mean SD, Median, Range (Months) Factor
Continued PEG Use (n [ 5)
Follow-up time (months)
10.6 14.0, 6.0, 1e35
Successful Wean from PEG (n [ 11)
P Value
16.8 17.0, 17.0, 3e38
0.23
Days with dysphagia after surgery 322.6 437.6, 180.0, 18e1085 104.7 97.5, 90.0, 14e365
0.39
5.0 4.7, 7.0, 0e10
0.11
Discomfort level
1.3 2.5, 0.0, 0e10
PEG, percutaneous endoscopic gastrostomy.
oral stage is a reflex action, termed the pharyngeal stage. This reflex involves a group of precise actions. There is elevation and retraction of the soft palate and closure of the nasopharynx, upper esophageal sphincter relaxation, laryngeal closure, tongue loading and propulsion, and pharyngeal contraction (5). This complex and coordinated pattern of events serves not only to guide the bolus through the pharynx into the esophagus, but it also serves to protect the larynx and airways (11). This entire process, although complex, is completed in about 1 second (5). Neural control of these stages primarily involves three areas of the medulla: the nucleus solitaries, the adjacent reticular formation, and the nucleus ambiguous. Cranial nerves V, VII, IX, X, XI, and XII are also intimately involved in the swallowing process (11). In our study, we sought to analyze the effects of location of the surgical lesion along the midbraineponsemedulla axis on continued dysphagia manifesting as EFD. Location was defined as whether the majority of pathology was intraparenchymal (cerebellar), involving the lower brainstem (bottom 50% of pons and medulla), upper brainstem (upper 50% of pons and midbrain), or both (Figure 1AeC). We anticipated that most patients with EFD would have pathology involving the lower regions. Of all 56 patients, 25 (44.6%) had the majority of their
pathology involving the lower regions. The majority (8/16 [50%]) of the EFD group had pathology involving the lower regions; however, this finding was not statistically significant (P ¼ 0.42) to implicate a lower location on the midbraineponsemedullary axis in an increased incidence of EFD. The surgical approach was analyzed in our study to examine its effect on incidence of EFD. Surgical approaches were differentiated as midline (standard midline suboccipital craniotomy) and lateral (including retromastoid, far lateral, and extreme far lateral approaches). We proposed that a lateral approach would more likely result in aspiration and dysphagia because of the pathology often being involved within the cranial nerves and the surgical manipulation of these nerves. Of 34 patients with a lateral approach, 13 (38.2%) demonstrated dysphagia at discharge (P ¼ 0.047), revealing a significantly increased incidence of EFD with manipulation of the lower cranial nerves. It is of importance to note that no patients who had a microvascular decompression for facial pain were included in this series, for no one among them had difficulty swallowing postoperatively nor were any swallow evaluations ordered. Despite its seriousness and the established assessment and treatment options, Table 8. Association of EFD with Location of Pathology
Table 7. Comparison in Average Operative Time (in Minutes) EFD Yes (n ¼ 16) No (n ¼ 40)
Mean SD, Median, Range 287.9 165.8, 235.0, 45e632 284.7 154.2, 237.5, 114e724
EFD, enteral feeding at discharge.
Location Along the BrainstemePonse Medullary Axis
Dysphagia, P n (%) Value
P Value Intraparenchymal (n ¼ 7) 0.86
1 (14.3)
Lower (n ¼ 25)
8 (32.0)
Upper (n ¼ 21)
5 (23.8)
Upper/lower (n ¼ 3)
2 (66.7)
EFD, enteral feeding at discharge.
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0.42
few studies have been performed that evaluate swallowing function after p-fossa surgery. Thompson et al. states that the best way to avoid serious consequences resulting from dysphagia after p-fossa surgery is to delay extubation until the patient is fully stable. After the necessary delay, vocal cords should be evaluated after extubation, and an analysis of swallowing function should be performed (11), via a modified barium swallow test (5, 11). Patients may need multiple in-house swallowing evaluations, and having greater than one study indicates that patients will most likely have aspiration and dysphagia at discharge (P < 0.01 for both). This would eliminate postoperative respiratory problems and aspiration pneumonia that follow p-fossa surgery. Our data indicate that aspiration is a significant predictor for EFD (P < 0.01), and majority (93.8%) of patients with EFD demonstrated aspiration at least once during the postoperative course. Patients who are at high risk of dysphagia must be screened prior to eating. Swallowing therapy with dietary modification, altered swallowing posture, and tailored swallowing techniques have shown effectiveness in managing patients with dysphagia (5). Speechelanguage pathologists are primarily responsible in administering both the management and assessment of swallowing dysfunction (7). There are several studies that assess swallowing in children after such surgeries, but to our knowledge there have been no evaluations of postoperative swallowing function in adults. In our center, adults make up the majority of patients undergoing p-fossa surgery; thus, we hoped to evaluate the factors responsible for prolonged dysphagia in adults after p-fossa surgery. In our study, older age of patient was significantly associated with both aspiration (P ¼ 0.01) and EFD (P < 0.01). The median age of patients exhibiting aspiration was 58 versus 46 years for those without aspiration. Similarly, the mean age for patients with EFD was 60.5 years and 49 years for those without EFD. It is important to note that out of 16 patients with EFD, only 5 (31.2%) still required PEG tube at last follow-up. Thus, the majority of patients (n ¼ 11/16 [68.8%]) who were discharged with EFD did not need prolonged enteral feeding. More importantly, only 5/56 (9%) patients who had pfossa surgery needed enteral feeding at last follow-up (median 10 months).
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Figure 1. Imaging demonstrating posterior fossa abnormalities. (A) T1 magnetic resonance imaging (MRI) with contrast showing an intraparenchymal hemangioblastoma. (B) Computed tomography
Furthermore, 4 of the 16 patients with dysphagia demonstrated swallowing difficulty prior to surgery, and 2 of these still required PEG feeding at last follow-up. Thus, of all patients with no dysphagia preoperatively, only 3 of 53 (5.6%) needed continued enteral feeding after p-fossa surgery. Our data suggest that 29% of patients having p-fossa surgery will demonstrate dysphagia postoperatively. The discrepancy between our study and that reported by Morgan et al. (73%) may be due to methodological differences. Morgan et al. included only pediatric patients with tumor resection and analyzed a small number of patients (n ¼ 8) in their study. It is impossible at this time to predict which patients will have chronic dysphagia and which patients will recover swallowing function (10). Few studies of dysphagia after p-fossa surgery have been conducted (all in pediatric population) and we recommend that further studies be conducted on complications surrounding p-fossa surgery. In order to reduce complications resulting from aspiration, we also recommend swallow evaluations postoperatively in all patients who have undergone these procedures with the exception of trigeminal nerve decompression. Our findings show that most patients who demonstrate EFD will not have longterm swallowing dysfunction, but we feel that longer follow-ups are needed.
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angiogram demonstrating a left vertebral artery aneurysm adjacent to the lower brainstem. (C) T1 MRI with contrast demonstrating cystic cerebellopontine mass with upper and lower brainstem compression.
CONCLUSION Despite the large number of patients with dysphagia following p-fossa surgery (29%), only a small number of patients (9%) required continued feeding through enteral tube. Aspiration, in addition to swallowing dysfunction leading to pneumonia, may contribute to significantly increased incidences of EFD. We recommend swallowing studies in patients with p-fossa surgeries and enteral feeding tubes for those who aspirate. REFERENCES 1. Buchholz DW: Oropharyngeal dysphagia due to iatrogenic neurological dysfunction. Dysphagia 10:248-254, 1995. 2. Cornwell PL, Murdoch BE, Ward EC, Morgan A: Dysarthria and dysphagia following treatment for a fourth ventricle choroid plexus papilloma. J Clin Neurosci 10:506-512, 2002. 3. Ertekin C, Amydogdu I, Yuceya N, Tarlaci S, Kiylioglu N, Pehlivan M, Celebi G: Electrodiagnostic methods for neurogenic dysphagia. Electroencephalogr Clin Neurophysiol 109: 331-340, 1998. 4. Ildan F, Tuna M, Erman T, Gocer AI, Zeren M, Cetinalp E: The evaluation and comparison of cerebellar mutism in children and adults after posterior fossa surgery: report of two adult cases and review of the literature. Acta Neurochir 144:463-473, 2002.
6. Mei C, Morgan AT: Incidence of mutism, dysarthria, and dysphagia associated with childhood posterior fossa tumour. Childs Nerv Syst 27: 1129-1136, 2011. 7. Morgan AT, Mageandran SD, Mei C: Incidence and clinical presentation of dysarthria and dysphagia in the acute setting following paediatric traumatic brain injury. Child Care Health Dev 36:44-53, 2009. 8. Morgan AT, Sell D, Ryan M, Raynsford E, Hayward R: Pre and post-surgical dysphagia outcome associated with posterior fossa tumour in children. J Neurooncol 87:347-354, 2008. 9. Newman LA, Boop FA, Sandford RA, Thompson JW, Temple CK, Duntsch CD: Postoperative swallowing function after posterior fossa tumor resection in pediatric patients. Childs Nerv Syst 22:1296-1300, 2006. 10. Peirie S, Wajeman S, Vivant R, St Guily JL: Swallowing difficulties for cerebellar stroke may recover beyond three years. Am J Otolaryngol 20:314-317, 1999. 11. Thompson JW, Newman L, Boop FA, Sanford RA: Management of postoperative swallowing dysfunction after ependymoma surgery. Childs Nerv Syst 25:1249-1252, 2009. Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 8 May 2012; accepted 8 January 2013 Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2013.01.035 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
5. Lind CD: Dysphagia: evaluation and treatment. Gastroenterol Clin N Am 32:553-575, 2003.
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Dysphagia Following Posterior Fossa Surgery in Adults Rishi Wadhwa1, Jamie Toms1, Prashant Chittiboina1, Tamir Tawfik1, Chad Glenn1, Gloria Caldito2, Bharat Guthikonda1, Anil Nanda1
Key words Aspiration - Dysphagia - Enteral tube - Posterior fossa -
Abbreviations and Acronyms EFD: Enteral feeding at discharge MLR: Multiple logistic regression PEG: Percutaneous endoscopic gastrostomy p-fossa: Posterior fossa
- OBJECTIVE:
Our study seeks to assess the incidence of aspiration and prolonged dysphagia needing enteral feeding at discharge (EFD) in adults after posterior fossa (p-fossa) surgery.
- METHODS:
A retrospective review was done on 56 patients with p-fossa surgery who needed a swallowing evaluation postoperatively. Questionnaires were sent to patients with EFD. Using univariate and multiple logistic regression analysis, risk factors for aspiration, EFD, and continued enteral feeds were identified.
- RESULTS:
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Most patients were male and had p-fossa tumors. Multiple swallowing evaluations were needed in 25 (45%) patients. Aspiration was seen in 23 (41%) and 16 (27%) had EFD. Older age and number of evaluations were significantly associated with both aspiration and EFD (P < 0.05). Lateral approach was significantly associated with EFD (P [ 0.047). In addition, multiple logistic regression identified aspiration as an independent significant predictor for EFD (P < 0.01). Mean operative time and tumor location did not have a significant correlation with EFD. At mean follow-up (15 months), only 5/16 needed continued enteral feeds.
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- CONCLUSION:
From the Departments of 1Neurosurgery and 2 Biometry, Louisiana State University Health Sciences Center, Shreveport, Shreveport, Louisiana, USA To whom correspondence should be addressed: Anil Nanda, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2013.01.035 Journal homepage: www.WORLDNEUROSURGERY.org
INTRODUCTION The posterior fossa (p-fossa) is an area including the brain regions and cranial nerves below the tentorium (8). These regions not only are crucial in wakefulness, speech, swallowing, hearing, facial sensation and musculature, and tongue movement, but they are also a common site for many types of tumors, vascular lesions, infection, and congenital abnormalities. Many of these lesions require surgical management (2, 6), and many complications can occur because of crowding of this small space by critical structures. As a result, patients undergoing p-fossa surgery may present with postoperative hydrocephalus, vertigo, deafness, facial numbness or weakness, tongue numbness or weakness, dysphonia, mutism, and dysphagia (1, 2, 4, 6, 8). A known complication after p-fossa surgery is swallowing dysfunction, or dysphagia (10). Physiologically, swallowing is generally characterized by four stages: an oral preparatory stage, an oral stage, a pharyngeal stage, and an
Although 27% patients had EFD after p-fossa surgery, only 5/56 (9%) required continued enteral feeding. Aspiration, age, and lateral surgical approach is associated with EFD. In patients who demonstrate aspiration, we recommend placement of enteral feeding tube. Although most will not require continued enteral feeding at follow-up, longer follow-ups are needed.
esophageal stage (3, 5, 11). In the event that any these four stages fail, a bolus cannot pass normally from the oral cavity to the stomach and this condition is termed dysphagia (5). Dysphagia can also occur because of decreased neurologic status as well as impairment of the anatomic structures from the brainstem nuclei to the laryngeal muscles. This may result in disrupted initiation, coordination, or maintenance of swallowing. Common deficits that are present with dysphagia are abnormal tongue movement, poor jaw stability, inefficient chewing, impaired lip seal, multiple swallows to clear a bolus, and lack of awareness of dysphagia (7). Any of these deficits can lead to nutritional deficits, emotional and social disruption, a need for supplementary feeding, and life-threatening aspiration (7, 8, 11).
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Aspiration can lead to significant problems including pneumonia (7, 8), which is a major cause of mortality in children undergoing p-fossa surgery (9). It is imperative to detect aspiration quickly to prevent such disastrous outcomes (10). There are several studies that assess swallowing in children after p-fossa surgery, but to our knowledge there are no reported evaluations of postoperative swallowing function in adults. Our study seeks to assess the incidence of aspiration and dysphagia and subsequent outcomes in adults that have undergone p-fossa surgery. METHODS A retrospective review was conducted on all patients undergoing p-fossa surgery from July 2007 until September 2010, excluding those cases of neurovascular
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decompression in trigeminal neuralgia, after approval from the institutional review board. Data on 56 patients who had p-fossa surgery at the LSUHSC-Shreveport over a 3-year period was analyzed to evaluate swallowing function following surgery and determine risk factors for postoperative aspiration and dysphagia. For those patients that were manifesting aspiration and/or dysphagia, further analysis was performed to evaluate the number and type of swallowing evaluations as well as status of swallowing function at discharge. A certified speech/language pathologist did bedside swallowing evaluations if patients deemed to be at any risk for aspiration or dysphagia by the neurosurgical team and/or nursing staff. Clinical findings that warranted further evaluation included having the patient swallow water and observing for the presence of breathlessness, wet hoarseness, or coughing. Evaluations were sometimes performed multiple times to account for improvement in postoperative examination. Barium swallow studies were done if bedside evaluation was not adequate or if aspiration was exhibited by the patient. “Silent” aspiration was radiologically confirmed with x-ray demonstration of contrast material passing through the vocal cords into the larynx. Enteral feeding tubes were placed 10e14 days postoperatively in those patients with enteral feeding at discharge (EFD). Patients who continued to demonstrate swallowing dysfunction at discharge were identified for further follow-up. Association was sought between two main outcomes— postoperative aspiration and EFD from hospital. We chose EFD as an intermediate outcome measure of swallowing function, with the need for prolonged enteral feeding as a final outcome measure. Sixteen patients failed their last swallow evaluation before discharge and were discharged with EFD. These patients were followed postdischarge and evaluated for dysphagia and long-term feeding through enteral tubes with follow-up questionnaires administered to the patients or their immediate caretakers. Statistical Techniques Chi-square or Fisher test were used to evaluate the association between outcome measures and categorical variables. Wilcoxon rank-sum test was used to compare
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continuous variables such as age and number of swallowing studies and also used to compare average follow-up time and discomfort level between patients with and without continued enteral feeding. Next, multiple logistic regression analysis was used to determine independent significant factors for swallowing dysfunction. Correlation between aspiration and dysphagia was determined along with EFD. The duration of extended enteral feeding for those with EFD was determined and additionally, sex, pathology type, location of tumor, operative time, preoperative dysphagia, difficulties with speech and tongue movements, and level of discomfort were all evaluated for this group.
Table 1. Summary Statistics on Patient Characteristics and Outcomes and Factors Significantly Associated with Aspiration and Dysphagia (N ¼ 56) Characteristic/ Outcome Male
32 (57.1)
Female
24 (42.9)
Pathology Abscess
1 (1.8)
Vascular
17 (30.4)
Congenital Tumor
Data on 56 patients who had p-fossa surgery at the LSUHSC-Shreveport over a 3-year period (2007e2010) were analyzed to evaluate swallowing function following surgery and determine risk factors for postoperative aspiration and dysphagia. Of the 56 patients with p-fossa surgery and swallowing evaluations, 25 patients had multiple tests and there were a total of 92 swallowing evaluations (Table 1). The majority of the patients were male (57.1%) and most had p-fossa tumors as the primary pathology (62.5%). Postoperatively, 23 (41.1%) aspirated at least once during hospital stay and 16 (28.6%) had EFD. The same factors appeared to contribute to both the incidence of aspiration and EFD, namely, age, number of evaluations, result of last swallow evaluation, and having barium for last study. A lateral sub-occipital surgical approach was significantly associated with EFD (P ¼ 0.047) but not with aspiration (P ¼ 0.09). In our study, EFD was significantly associated with aspiration and vice versa; the corollary being that there was significant correlation between incidence of aspiration during hospitalization and the need for EFD. Significantly higher proportions of patients with aspiration were observed among those with barium swallow study as their last swallow study prior to discharge (82.4%), and those who had multiple swallow evaluations postoperatively (88%). Significantly, the patients who demonstrated aspiration during the postoperative phase formed a much
2 (3.6) 35 (62.5)
Stroke
RESULTS
Number (%) or Mean SD, Median, Range
1 (1.8)
Multiple swallow evaluations*y
25 (44.6)
Enteral feeding at discharge (EFD)*
16 (28.6)
Aspirationy
23 (41.1)
Last swallow study was Barium*y
17 (20.4)
Location along brainstemeponsemedullary axis Intraparenchymal
7 (12.5)
Lower
25 (44.6)
Upper
21 (37.5)
Upper/lower
3 (5.4)
Approachy Lateral
34 (60.7)
Midline
22 (39.3) y
Age (years)*
49.3 17.5, 51.0, 8e81
Number of evaluations*y
1.6 1.1, 1.0, 1e8
Operative time (minutes)
285.6 156.1, 237.5, 45e724
*Significantly associated with aspiration during hospitalization. ySignificantly associated with enteral feeding at discharge (or EFD).
higher proportion of those with EFD (93.8%) than those without EFD (20%) (P < 0.01) (Table 2). A higher proportion of patients with EFD were also observed in those with barium as their last swallow study (58.8%), and those needing multiple swallow evaluations (56.0%). Surgical approach to the p-fossa also significantly affected the occurrence of EFD, with the
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Table 2. Factors Significantly Associated with Aspiration During Hospitalization and EFD Proportion with Aspiration, Number (%)
Factor/Categories
P Value
Hospitalization <0.01
EFD No (n ¼ 40)
8 (20.0)
Yes (n ¼ 16)
15 (93.8) <0.01
Barium swallow study Yes (n ¼ 17)
14 (82.4)
No (n ¼ 39)
9 (23.1) <0.01
Number of evaluations Multiple (n ¼ 25)
22 (88.0)
Single (n ¼ 31)
1 (3.2) Proportion with Dysphagia, n (%)
EFD <0.01
Aspiration at least once during hospitalization Yes (n ¼ 23)
15 (65.2)
No (n ¼ 33)
1 (3.0) <0.01
Barium swallow study Yes (n ¼ 17)
10 (58.8)
No (n ¼ 39)
6 (15.4) <0.01
Number of swallow evaluations Multiple (n ¼ 25)
14 (56.0)
Single (n ¼ 31)
2 (6.4)
Surgical approach
0.047
Lateral (n ¼ 34)
13 (38.2)
Midline (n ¼ 22)
3 (13.6)
EFD, enteral feeding at discharge.
Table 3. Factors Significantly Associated with Postoperative Aspiration and EFD, Mean SD, Median, Range Factor
Had Aspiration (n [ 23)
No Aspiration (n [ 33)
56.4 16.4, 58.0, 19e81
44.3 16.6, 46.0, 8e70
P Value
Postoperative aspiration Age Number of swallow studies
2.3 1.3, 2.0, 1e8
1.2 0.6, 1.0, 1e4
Had Dysphagia (n [ 16)
No Dysphagia (n [ 40)
60.1 16.0, 60.5, 19e81
45.0 16.3, 49.0, 8e70
0.01 <0.01
EFD Age Number of swallowing studies
2.4 1.6, 2.0, 1e8
EFD, enteral feeding at discharge.
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1.4 0.7, 1.0, 1e4
<0.01 <0.01
lateral approach causing a significantly higher proportion of patients (38.2%) with EFD versus the midline approach (13.6%) (P ¼ 0.47) (Table 2). Using the Wilcoxon’s rank-sum test, we found that a higher age and an increasing number of swallow evaluations were associated with both the incidence of aspiration and with EFD (Table 3). Multiple logistic regression analysis identified the number of swallowing evaluations as an independent predictor of postoperative aspiration. Likewise, result of multiple logistic regression analysis identifies aspiration as the only independent significant predictor for EFD (Table 4). Adjusted for the effects of other significant factors, odds for dysphagia among patients who aspirated during the postoperative period were 58.8 times the odds of patients who did not aspirate. Summary statistics for the 16 patients with EFD are shown in Table 5. Median follow-up time for these patients was 10 months (ranging from 1 to 38 months). At last follow-up, there were 5 (31.2%) patients still with percutaneous endoscopic gastrostomy (PEG); 10 (62.5%) had speech/ tongue problems, 6 (40%) had some form of discomfort associated with enteral feeding (discomfort level >0), and 4 (25%) patients had died. Four patients with postoperative dysphagia had swallowing problems before surgery attributed to their preoperative pathology. Among the 4 patients who had swallowing problems before surgery, 2 (50%) had continued PEG use at the last follow-up. Factors significantly associated with continued PEG use were a persistent difficulty in swallowing both solids and liquids. The proportion of patients with continued PEG use was higher among those with problems swallowing solids and liquids (55.6% for both). There were no significant differences in average follow-up time in months, days with swallow problem after surgery, and discomfort level between patients with and without continued feeding with PEG tube (Table 6). It can be noted that none of the significant factors for EFD and aspiration were significantly associated with continued dysphagia and PEG usage. The nonsignificant results are likely due to the small sample sizes for the two groups compared (5 and 11). Mean operative times between those with and without EFD were 287 and 284
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Table 4. Independent Significant Predictors of Postoperative Aspiration Predictor/Factor
OR
95% CI
P Value
16.7
2.8e98.4
<0.01
58.8
6.8e500.0
<0.01
Postoperative aspiration Number of swallowing studies EFD Aspiration EFD, enteral feeding at discharge; OR, odds ratio.
Table 5. Summary Statistics on Patients with EFD and Significant Factors for Continued PEG Use (N ¼ 16) Characteristic/Outcome
Number (%) or Mean SD, Median, Range
Male
9 (56.2)
Multiple swallow studies in hospital
14 (87.5)
Last study was barium swallow study
10 (62.5)
Continued PEG at last follow-up
5 (31.2)
Continued speech/tongue problem
10 (62.5)
Difficulty with swallowing solids*
9 (56.2)
Difficulty with swallowing liquids*
9 (56.2)
Discomfort level >0
6 (40.0)
Pathology Tumor
10 (62.5)
Vascular
6 (37.5)
Location of lesion along the brainstemeponsemedullary axis Intraparenchymal
1 (6.2)
Lower
8 (50.0)
Upper
5 (31.2)
Upper/Lower
2 (12.5)
Had aspiration (while in hospital)
15 (93.8)
Had swallow problem before surgery
3 (18.8)
Had swallow problem before surgery
16 (100.0)
Surgical approach Lateral
13 (81.2)
Midline
3 (18.8)
Died
4 (25.0) 49.5 182.1, 0, 0e730
Days with dysphagia before surgery Days with dysphagia after surgery
172.8 261.3, 90.0, 14e1085 60.1 16.0, 60.5, 19e81
Age (years)
2.4 1.6, 2.0, 1e8
Number of swallowing studies Operative time (minutes)
287.9 165.8, 235.0, 45e632 14.9 12.7, 10.0, 1e38
Follow-up time (months) after discharge EFD, enteral feeding at discharge; PEG, percutaneous endoscopic gastrostomy. *Significantly associated with continued dysphagia and PEG use.
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minutes (P ¼ 0.86), respectively (Table 7). The medulla was the location of pathology in 25 (44.6%) patients in the entire study group and 8 (50%) patients in the EFD group. The location of the lesion leading to p-fossa surgery was not significantly associated with EFD (P ¼ 0.42) (Table 8). Two of the patients with continued PEG use at last follow-up died. One patient died at 10 days postdischarge from cardiorespiratory failure and the other patient died at 60 days postdischarge from an unknown cause. Two other patients in the study expired. One passed away 24 days postoperation from a gastrointestinal bleed but who was no longer dependent on enteral feeding. The other had continued PEG use at the 5-month follow-up but had a complete resolution of postoperative dysphagia. The PEG was reinserted to manage their newly discovered pancreatic cancer (to which this patient succumbed during the study period). In the small sample size of patients with EFD (16 patients), no factors were observed to be significantly associated with death. Among patients with p-fossa surgery, aspiration and EFD were significantly correlated and were predictive of each other. Among those with EFD, problems with swallowing solids and liquids were significantly associated with continued dysphagia and PEG use. DISCUSSION Dysphagia, or swallowing dysfunction, is a devastating complication that can affect individuals after p-fossa surgery. This complication can lead to malnutrition and psychological consequences, as well as aspiration (8). Because of these lifealtering and fatal effects of swallowing dysfunction, it is imperative to accurately diagnose swallowing abnormalities after surgery (9). In a pediatric study by Morgan et al., 73% of patients who underwent pfossa tumor resection demonstrated dysphagia during the first 2 weeks of postoperative recovery (8). There are four stages of swallowing beginning with mastication and bolus formation as part of the oral preparatory stage. After the bolus has been formed in the first stage, the second stage utilizes the tongue and hard palate to transport the bolus to the posterior portion of the oral cavity; this is termed the oral stage (11). Following the
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Table 6. Comparisons Between Patients with and without Continued PEG Use, Mean SD, Median, Range (Months) Factor
Continued PEG Use (n [ 5)
Follow-up time (months)
10.6 14.0, 6.0, 1e35
Successful Wean from PEG (n [ 11)
P Value
16.8 17.0, 17.0, 3e38
0.23
Days with dysphagia after surgery 322.6 437.6, 180.0, 18e1085 104.7 97.5, 90.0, 14e365
0.39
5.0 4.7, 7.0, 0e10
0.11
Discomfort level
1.3 2.5, 0.0, 0e10
PEG, percutaneous endoscopic gastrostomy.
oral stage is a reflex action, termed the pharyngeal stage. This reflex involves a group of precise actions. There is elevation and retraction of the soft palate and closure of the nasopharynx, upper esophageal sphincter relaxation, laryngeal closure, tongue loading and propulsion, and pharyngeal contraction (5). This complex and coordinated pattern of events serves not only to guide the bolus through the pharynx into the esophagus, but it also serves to protect the larynx and airways (11). This entire process, although complex, is completed in about 1 second (5). Neural control of these stages primarily involves three areas of the medulla: the nucleus solitaries, the adjacent reticular formation, and the nucleus ambiguous. Cranial nerves V, VII, IX, X, XI, and XII are also intimately involved in the swallowing process (11). In our study, we sought to analyze the effects of location of the surgical lesion along the midbraineponsemedulla axis on continued dysphagia manifesting as EFD. Location was defined as whether the majority of pathology was intraparenchymal (cerebellar), involving the lower brainstem (bottom 50% of pons and medulla), upper brainstem (upper 50% of pons and midbrain), or both (Figure 1AeC). We anticipated that most patients with EFD would have pathology involving the lower regions. Of all 56 patients, 25 (44.6%) had the majority of their
pathology involving the lower regions. The majority (8/16 [50%]) of the EFD group had pathology involving the lower regions; however, this finding was not statistically significant (P ¼ 0.42) to implicate a lower location on the midbraineponsemedullary axis in an increased incidence of EFD. The surgical approach was analyzed in our study to examine its effect on incidence of EFD. Surgical approaches were differentiated as midline (standard midline suboccipital craniotomy) and lateral (including retromastoid, far lateral, and extreme far lateral approaches). We proposed that a lateral approach would more likely result in aspiration and dysphagia because of the pathology often being involved within the cranial nerves and the surgical manipulation of these nerves. Of 34 patients with a lateral approach, 13 (38.2%) demonstrated dysphagia at discharge (P ¼ 0.047), revealing a significantly increased incidence of EFD with manipulation of the lower cranial nerves. It is of importance to note that no patients who had a microvascular decompression for facial pain were included in this series, for no one among them had difficulty swallowing postoperatively nor were any swallow evaluations ordered. Despite its seriousness and the established assessment and treatment options, Table 8. Association of EFD with Location of Pathology
Table 7. Comparison in Average Operative Time (in Minutes) EFD Yes (n ¼ 16) No (n ¼ 40)
Mean SD, Median, Range 287.9 165.8, 235.0, 45e632 284.7 154.2, 237.5, 114e724
EFD, enteral feeding at discharge.
Location Along the BrainstemePonse Medullary Axis
Dysphagia, P n (%) Value
P Value Intraparenchymal (n ¼ 7) 0.86
1 (14.3)
Lower (n ¼ 25)
8 (32.0)
Upper (n ¼ 21)
5 (23.8)
Upper/lower (n ¼ 3)
2 (66.7)
EFD, enteral feeding at discharge.
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0.42
few studies have been performed that evaluate swallowing function after p-fossa surgery. Thompson et al. states that the best way to avoid serious consequences resulting from dysphagia after p-fossa surgery is to delay extubation until the patient is fully stable. After the necessary delay, vocal cords should be evaluated after extubation, and an analysis of swallowing function should be performed (11), via a modified barium swallow test (5, 11). Patients may need multiple in-house swallowing evaluations, and having greater than one study indicates that patients will most likely have aspiration and dysphagia at discharge (P < 0.01 for both). This would eliminate postoperative respiratory problems and aspiration pneumonia that follow p-fossa surgery. Our data indicate that aspiration is a significant predictor for EFD (P < 0.01), and majority (93.8%) of patients with EFD demonstrated aspiration at least once during the postoperative course. Patients who are at high risk of dysphagia must be screened prior to eating. Swallowing therapy with dietary modification, altered swallowing posture, and tailored swallowing techniques have shown effectiveness in managing patients with dysphagia (5). Speechelanguage pathologists are primarily responsible in administering both the management and assessment of swallowing dysfunction (7). There are several studies that assess swallowing in children after such surgeries, but to our knowledge there have been no evaluations of postoperative swallowing function in adults. In our center, adults make up the majority of patients undergoing p-fossa surgery; thus, we hoped to evaluate the factors responsible for prolonged dysphagia in adults after p-fossa surgery. In our study, older age of patient was significantly associated with both aspiration (P ¼ 0.01) and EFD (P < 0.01). The median age of patients exhibiting aspiration was 58 versus 46 years for those without aspiration. Similarly, the mean age for patients with EFD was 60.5 years and 49 years for those without EFD. It is important to note that out of 16 patients with EFD, only 5 (31.2%) still required PEG tube at last follow-up. Thus, the majority of patients (n ¼ 11/16 [68.8%]) who were discharged with EFD did not need prolonged enteral feeding. More importantly, only 5/56 (9%) patients who had pfossa surgery needed enteral feeding at last follow-up (median 10 months).
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Figure 1. Imaging demonstrating posterior fossa abnormalities. (A) T1 magnetic resonance imaging (MRI) with contrast showing an intraparenchymal hemangioblastoma. (B) Computed tomography
Furthermore, 4 of the 16 patients with dysphagia demonstrated swallowing difficulty prior to surgery, and 2 of these still required PEG feeding at last follow-up. Thus, of all patients with no dysphagia preoperatively, only 3 of 53 (5.6%) needed continued enteral feeding after p-fossa surgery. Our data suggest that 29% of patients having p-fossa surgery will demonstrate dysphagia postoperatively. The discrepancy between our study and that reported by Morgan et al. (73%) may be due to methodological differences. Morgan et al. included only pediatric patients with tumor resection and analyzed a small number of patients (n ¼ 8) in their study. It is impossible at this time to predict which patients will have chronic dysphagia and which patients will recover swallowing function (10). Few studies of dysphagia after p-fossa surgery have been conducted (all in pediatric population) and we recommend that further studies be conducted on complications surrounding p-fossa surgery. In order to reduce complications resulting from aspiration, we also recommend swallow evaluations postoperatively in all patients who have undergone these procedures with the exception of trigeminal nerve decompression. Our findings show that most patients who demonstrate EFD will not have longterm swallowing dysfunction, but we feel that longer follow-ups are needed.
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angiogram demonstrating a left vertebral artery aneurysm adjacent to the lower brainstem. (C) T1 MRI with contrast demonstrating cystic cerebellopontine mass with upper and lower brainstem compression.
CONCLUSION Despite the large number of patients with dysphagia following p-fossa surgery (29%), only a small number of patients (9%) required continued feeding through enteral tube. Aspiration, in addition to swallowing dysfunction leading to pneumonia, may contribute to significantly increased incidences of EFD. We recommend swallowing studies in patients with p-fossa surgeries and enteral feeding tubes for those who aspirate. REFERENCES 1. Buchholz DW: Oropharyngeal dysphagia due to iatrogenic neurological dysfunction. Dysphagia 10:248-254, 1995. 2. Cornwell PL, Murdoch BE, Ward EC, Morgan A: Dysarthria and dysphagia following treatment for a fourth ventricle choroid plexus papilloma. J Clin Neurosci 10:506-512, 2002. 3. Ertekin C, Amydogdu I, Yuceya N, Tarlaci S, Kiylioglu N, Pehlivan M, Celebi G: Electrodiagnostic methods for neurogenic dysphagia. Electroencephalogr Clin Neurophysiol 109: 331-340, 1998. 4. Ildan F, Tuna M, Erman T, Gocer AI, Zeren M, Cetinalp E: The evaluation and comparison of cerebellar mutism in children and adults after posterior fossa surgery: report of two adult cases and review of the literature. Acta Neurochir 144:463-473, 2002.
6. Mei C, Morgan AT: Incidence of mutism, dysarthria, and dysphagia associated with childhood posterior fossa tumour. Childs Nerv Syst 27: 1129-1136, 2011. 7. Morgan AT, Mageandran SD, Mei C: Incidence and clinical presentation of dysarthria and dysphagia in the acute setting following paediatric traumatic brain injury. Child Care Health Dev 36:44-53, 2009. 8. Morgan AT, Sell D, Ryan M, Raynsford E, Hayward R: Pre and post-surgical dysphagia outcome associated with posterior fossa tumour in children. J Neurooncol 87:347-354, 2008. 9. Newman LA, Boop FA, Sandford RA, Thompson JW, Temple CK, Duntsch CD: Postoperative swallowing function after posterior fossa tumor resection in pediatric patients. Childs Nerv Syst 22:1296-1300, 2006. 10. Peirie S, Wajeman S, Vivant R, St Guily JL: Swallowing difficulties for cerebellar stroke may recover beyond three years. Am J Otolaryngol 20:314-317, 1999. 11. Thompson JW, Newman L, Boop FA, Sanford RA: Management of postoperative swallowing dysfunction after ependymoma surgery. Childs Nerv Syst 25:1249-1252, 2009. Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 8 May 2012; accepted 8 January 2013 Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2013.01.035 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
5. Lind CD: Dysphagia: evaluation and treatment. Gastroenterol Clin N Am 32:553-575, 2003.
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