Dysphagia as a complication of posterior fossa surgery in adults

Predicting dysphagia in children undergoing surgery for posterior fossa tumors

PURPOSE

Posterior fossa tumors (PFTs) are the most common type of brain tumor in children. Dysphagia is a known complication of PFT resection in children, but data regarding risk factors and clinical course are sparse.

METHODS

The records of all children who underwent resection of posterior fossa tumor between April 2007 and May 2017 at our institution were analyzed. Clinical, radiographic, histologic data were gathered. Swallowing function was assessed immediately postoperatively and at 1-year follow-up.

RESULTS

A total of 197 patients were included. Forty-three (21.8%) patients developed dysphagia after surgery. Patients who developed dysphagia were younger (4.5 vs. 7.2 years, p < 0.01), were more likely to have brainstem compression (74.4% vs. 57.8%, p < 0.03) or invasion (14.0 vs. 9.7%, p < 0.03), and were more likely to have ependymoma (27.9% vs. 13.6%, p < 0.01) or ATRT (atypical teratoid/rhabdoid tumor) (9.3% vs. 3.9%, p < 0.01). Patients with postoperative dysphagia also had a longer length of stay (33.7 vs. 12.7 days, p < 0.01) and were more likely to be discharged to inpatient rehabilitation (25.6% vs. 9.1%, p < 0.01). Ten patients (5.1%) were PEG-dependent by 1-year follow-up. These patients were younger (2.7 vs. 5.6 years, p < 0.01), had a longer length of stay (55.5 vs. 27.4 days, p < 0.01), and were more likely to have ATRT (30.0% vs. 0.0%, p < 0.01). Recovery was not associated with tumor grade or extent of resection.

CONCLUSIONS

Dysphagia after PFT resection is associated with younger age, aggressive tumor histology, and increased healthcare utilization. While most patients recover, a small percentage are still dependent on enteral feeding at 1-year follow-up. Further research is needed to identify factors associated with persistent deficits.

Gastrointestinal Tract: A Neglected Guardian Angel?

Role of the gastrointestinal (GI) system is not limited to the digestion of food and absorption of water and nutrients. Gastrointestinal mucosa forms a barrier preventing translocation of microbes into the blood. Upper GI tract performs important function of swallowing and prevention of aspiration, failure of which mandates enteral tube feeding. Rate of gastric emptying depends on gastric volume and contents and delayed emptying is observed both in solid and in fatty food. Cricoid pressure during intubation is an important intervention for prevention of aspiration in critically ill patients who are considered as full stomach. To utilize mucosal barrier function optimally, hemodynamically stable patients should preferably receive enteral nutrition even if they are on small doses of vasopressors. Post-pyloric feeds may reduce risk of aspiration and hence are recommended for patients who are deemed to have high risk for aspiration. Bowel sounds have poor reproducibility, sensitivity, specificity, accuracy, and interobserver agreement, and absent bowel sounds should not be considered as a contraindication to enteral feeding.

How to cite this article: Kothekar AT, Kulkarni AP. Gastrointestinal Tract: A Neglected Guardian Angel? Indian J Crit Care Med 2020;24(Suppl 4):S146–S151.

A Prospective Evaluation of Swallowing and Speech in Patients with Neurofibromatosis Type 2

Objective  Neurofibromatosis type 2 (NF2) patients report that swallowing and speech problems significantly affect their quality of life, but the etiology of these phenomena is poorly understood. Swallowing and speech deficits may arise due to the neuropathy of involved nerves, due to posterior fossa tumor growth, or as iatrogenic effects from neurosurgical procedures to remove these tumors. This study aims to identify the natural history of swallowing and speech deficits in an NF2 cohort and to characterize the factors that may lead to those deficits. Methods  Subjects ( n  = 168) were enrolled in a prospective, longitudinal study of NF2 with yearly imaging and clinical exams. The patients completed a self-reported questionnaire that included responses regarding subjective swallowing and speech dysfunction. A formal speech-language pathology evaluation and modified barium swallow (MBS) study (reported as American Speech-Language Hearing Association [ASHA] swallowing independency score from 1 through 7) was obtained when a speech/swallowing deficit was reported on the questionnaire. Results  Of the 168 enrolled subjects, 55 (33%, median age = 31 years) reported subjective speech and/or swallowing deficits. These patients underwent one ( n  = 37) or multiple ( n  = 18) MBS studies during 44.8 ± 10.4 months follow-up. During MBS, a majority demonstrated near-normal swallowing (ASHA score >6, 82%), and no evidence of aspiration (aspiration/laryngeal penetration score = 1, 96%). Prior to initial MBS consultation, 38 (69%) patients had undergone relevant neurosurgical procedures. In those with recent (<1 week) posterior fossa surgery ( n  = 12), 2 (17%) patients had severe dysphagia and high aspiration risk on postoperative MBS. Both of these patients recovered to functionally independent swallowing status. Unilateral ( n  = 10) or bilateral ( n  = 6) tongue deficits unrelated to previous history suggestive of hypoglossal nerve injury were detected on clinical examination. There was a correlation between the presence of dysarthria and tongue deficits and tumors associated with the hypoglossal canal noted on imaging. Conclusion  A large proportion of patients with NF2 report speech and swallow deficits that are not evident on objective measurements. We also found hypoglossal neuropathy unrelated to prior surgical interventions. Our findings suggest that swallowing and speech problems in NF2 are associated with lower cranial nerve neuropathy, some due to compressive effects of posterior fossa tumors. Adaptation over the course of the disease allows for the compensation of these deficits and subsequent normal findings on objective testing.