2024-03-20 11 Panel 8 Swallowing Voice and the Altered Pediatric Airway

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Panel 8: Swallowing, Voice, and the Altered Pediatric Airway. Moderator: Claudia Schweiger (ENT), Speakers: Rebecca Maunsell (ENT), David Molter (ENT), Bridget Harrington (SLP).

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>> Amount of them that will still have dysphagia after supraglutoplasty. So we cannot just discharge patients and ignore them after supraglutoplasty. They might actually need an evaluation and have persistent issues with swallowing even after surgery. And what about reconstructive surgery, LTRs and PCTRs and extended PCTRs? Can our airway intervention have a negative repercussion or aggravate the swallowing dysfunction? And who and when do we assess for dysphagia before an airway intervention? Now here we have a lot of discussion around this and because we can potentially make things worse. And obviously if we have a child that doesn’t swallow well in the first place, we will definitely make that worse. But what about the child that apparently swallows well? How far do we go with this investigation? If we have a child like this who needs to get from a grade 4 subglottic stenosis to this, this is his surgery, it is pretty obvious that once we open this airway, this child is going to get more issues than he already has with swallowing. So we have to be careful with this before and continuously perioperative and after the surgery too. And we can get them to the right place. It doesn’t mean we don’t operate on these kids. But we have to really evaluate them well. And here there’s not much of a doubt that this needs to be done. But what about this other case? And this is one of the most common cases, the ex-premise. So the ex-premise that’s doing pretty much well, who’s 3 years old, good motor skills, apparently no cognitive impairment, has a trach since he is 4 months old, feeding, had long-term feeding issues but is feeding parietal but still has a gastrostomy that sometimes mom uses or not, is a bit selective, doesn’t have any acute episodes, apparently is doing well and thriving and is in a good time for surgery, has no symptoms associated to feeding, no vomiting, no choking or anything, and has this nasofibroscopy. Things look good. I don’t see any pooling. But what I do see is that we’re going to have to open the glottis. There is a glottis stenosis, there’s a complex laryngeal stenosis, glottis, subglottis and supraglottis, but I’m not going to show it here, that’s not the point. The point is I know that what I’m going to have to do as a surgeon to make this airway work to put air through the airway is to enlarge the glottis areas. So I know this can give this child a swallowing issue that he apparently doesn’t have. These are just considerations. I’m throwing this out here because we’re going to get all the answers from ISLP at the end of the session. And why do we get these problems with surgeries? Because we have scarring in the airway and we get a lot of areas that will be desensitized, unleveled vocal folds, scarring in the vocal folds, scarring when we use stents, around our stents, at the bottom of the top of our stents, fixation of the quicoretinoid joints, and once we expand the glottis and affix glottis, we might get problems and have a big impact on closure of the glottis at the glottis and supraglottic level. And I’ll show you some evidence that this is a problem. So we have to ask ourselves as airway surgeons, is this the right time to do this? And is this the best procedure? Or do I have to adjust my procedure? Every time we have to ask ourselves this question again and again. Is there a potential to compromise the glottis, the supraglottic closure? Am I going to need a posterior graft? And this is such a good opportunity to discuss this with SLPs who work with us because they too will know, they understand the surgery we’re doing and that’s how everything just fits in. If we speak to, if you work on your own and you’re asking an SLP for advice and she doesn’t know what surgery you’re going to do, she doesn’t know you’re going to expand the posterior glottis, you have to explain that to her. Is there a potential for sustained altered sensibility in this child? Are you going to do single or double stage? These are things that you can adapt your surgery depending on the potential for swallowing problems postoperatively. So what do we have to do as a clinical evaluation? Well the minimum, minimum clinical evaluation is the clinical evaluation that our SLPs do. When they are attentive to the anamnesis, the examination of the structures of the mouth, assessment of the uromodal skills, they’re observing drinking and feeding. As airway surgeons we tend to actually, as not as airway surgeons, as pneumologists, as any way, any one part of an aero digestive group or team, we all tend to do this all at the same time because we assume, we assume, we exchange our positions all the time as a team. But this is what the SLPs do really, really, really well to evaluate and this I think is the minimum investigation that we need to be doing in all cases for airway surgery, particularly for airway reconstruction. And for me the functional endoscopic evaluation of swallowing is also really, really useful. We have the scope in our hands. It’s very easily done even if we have to adapt and we can’t actually do it with introduction of food. We can still look at pooling of saliva, liquids, food in the peripheral sinus, penetration or aspiration. We can see if there is residue and this will give us, give us tips on how the, the child manages not only food but even saliva for me is already a good tip of what’s going on with this child swallowing before surgery. There is this brilliant, brilliant paper that I really like from Cincinnati group from Paul Wilging talking about the benefit of feeding assessment before pediatric reconstruction, describing their considerations on over 200 cases and the prediction for poor airway procedures, the findings were these. Feeding of secretions in the hyperpharynx, poor oral motor skills, allowing spillage of material into the hyperpharynx and residue. So this is what we have to be looking at either through nasal fibroscopy with food, without food or with modified functional endoscopic evaluation. This is for me is also a minimum evaluation before airway reconstruction. And in this case they were evaluating 77 of their patients with airway reconstruction and this actually changed their, sorry, this actually changed what they were doing post-surgery sometimes regarding postponing surgery or indicating alternative feeding through the peripatitive timing or even changing the procedure as I was talking to you before. This is another paper by the same group where they were looking at a group of I think 30 children that they were performing, that had undergone airway surgery and looking at the group that aspirated and the group that didn’t aspirate and the differences that they saw in their functional endoscopic evaluation and what now sounds quite obvious to us but it is a fact that children who aspirate have poor laryngeal closure and poor laryngeal closure timeliness and overall swallowing coordination. So that is a mark of a child that doesn’t swallow, has swallowing issues at least in the post-reverative period. I wasn’t going to include this because we don’t have much time but I cannot say, cannot end swallowing, anything about swallowing without talking about video fluoroscopy for a while, not that, as if I’m completely ignoring it. We do get around to doing this sometimes but for me in my practice this is not a routine exam for someone that is going through airway reconstruction. It might be that we do one or both but it’s not every time as we do with functional endoscopic evaluation. And sometimes a big limitation to this is because children are not intaking enough food to do the exam and we have to acknowledge that too. I don’t know if all the surgeons in the room have the perspective that you cannot ask for a video fluoroscopic swallowing study if the child does not eat per oral. So we have to consider that and also the radiation. We don’t want to keep repeating these evaluations in these children and that’s another thing, another positive point for the functional endoscopic evaluation that we can repeat this as many times as we like and as I was telling you as a surgeon we just have the scope in our hands so it’s really easy and the SLP next to me helping out. So the core messages for the, for, or considerations for this talk, knowing that this is something that we’re, is up to discussion I’m sure in every institution this might be a little bit different. This is kind of my view on things. But we should always consider the impact of airway surgery on swallowing because we need to cancel these patients and adjust expectations of the patients and of what we’ll need postoperatively. For congenital obstructive laryngotracheal anomalies in otherwise healthy children they should improve swallowing disorders but on a case to case depending particularly on underlying diseases we should make a decision on whether to perform one or both functional swallowing tests. And before airway surgery always evaluate the potential for glottic and supraglottic closure and sensitivity issues and the clinical evaluation of swallowing is imperative in all cases added to at least a nasofibroscopy and if possible always a endoscopic evaluation. Functional evaluation with endoscopic evaluation or a swallow, a barium swallow study is not always representative but is highly recommended in these cases. Children with comorbidities, children with indirect signs of swallowing issues which could be something that you found on your functional endoscopic evaluation and children with tracheostomies. Oops, sorry. Okay and we’ll leave the questions for the discussion if we have time later. Thank you. [applause] >> Hi, I’m Dave Moulter. Normally I spend very little time on the disclosure slide but I’d like to use a little time for this disclosure slide. I’m part of the board and we want you to be interested in our society so I’m disclosing that. Part of that is that we want to be able to provide resources for you and so we’re already working on being able to provide videos and transcripts in multiple languages of those videos that may be able to help you. We’re also developing over time resource materials for programs and we want to make sure that we don’t simply try to translate those because we want to remain culturally appropriate. So having built some stuff for Nicaragua before I know that I can’t just take my map from here and take it there. So we may be asking you in the future to help us to be able to try to meet your needs. The second thing is if you walked up to me and said, “Dave, I want to talk about speech surgery,” I would be thinking about the velopharynx and we’d be talking about sphincters and furloughs and all those other kind of things because that’s really what I think of when I’m thinking of speech surgery most of the time. I come from an institution that has a cleft pallet clinic or a craniofacial clinic that has been there for 45, 50 years. And so I have a huge database of previous VNEs and SVFs and it’s all formally done and it’s all in the computer and then if I say to myself, “Well, let’s look at the voice analysis over the –” we don’t have anything like that at all. We do not maintain those records. So this lecture is going to be a little bit of a do what I say, not what I do and encourage me and the group to try to be able to give you the facilities so that that’ll be something that’ll be easy for you to do in the future. So for decades it was decannulation first, swallow and voice were both distinct seconds. Most of our procedures open the airway at the sacrifice of cord function and particularly if that reconstruction extends to the cords. In all talks I’ve been taught to throw a chevrolet Jackson in there somewhere so he described a cordectomy in 1922. Great for airway, horrible for voice. I’m coming in and out but I’ll yell, I’m really a good yeller. And then from a standpoint of looking both at the literature and my experience there was some attention to voice that really started in the 80s and 90s but it became much more apparent in the 2000s. And I need to say we present ourself not paying as much attention to voice. I went to the ASHA website. Why? Because I think they have a great website. I really appreciate – I actually send my patients to there, I send my speech pathologist to there but when I looked there and I looked under aerodigestive it really didn’t talk much about speech. It talked about swallow, it talked about assessment methods and there’s certainly some overlap there but it wasn’t saying hey, speech is what we’re really going to give you in the aero program. And then I looked at the websites across multiple well-established long-term aerodigestive programs. We don’t even talk in our aerodigestive websites. Now I know some of that is advertisement and we don’t want to lead with something that we are not very good at. But you need to know that at this point I don’t think we are including speech as – or speech and voice as strongly as I think we could. So it’s always a little tricky when the author of the chart you’re using is sitting next to you but she is and so she was looking at how should we report our voice outcomes. It was more a method paper than a results paper and looked at 228 articles of which they brought down to 12. You probably know some of those articles already. In fact, you know most of those articles already. And what we got from that was the consensus auditory processing or perceptive evaluation or the CAPE was the most commonly used auditory perceptual instrument. From a standpoint of acoustic parameters it was fundamental frequency and maximal phonation time which is easy for us to do in the office. And from the standpoint of quality life it was the pediatric voice handicapped index that if you were trying to say well okay I’m going to make a database which one should I choose those would be three good answers to start with right there of how you should be thinking about these patients. And Dr. Alakon one of the things that he commented about in one of his papers is these are really independent. They are verified but the perception of quality of life may not be the same as the auditory or as the CAPE-5. So it really is independent data. You need to think of it that way. So what are the general outcomes after open airway surgery? And I think this is also a tricky place for me. I have a cleft palate team. I have a tracheostomy clinic. I have an aerodigestive clinic. So when someone has an airway reconstruction they’re not necessarily someone who is primarily based in the aero clinic. And so if we look at our history we have a lot that is reported about patients that have had open airway surgery but not being equivalent to members of the aero digestive clinic. And part of that is just because aero digestive clinics have grown in this time. But in general it’s worse if you’re coming through the cords. It’s worse if it’s a cricotracheal resection. It’s worse if you have a more number of surgeries. It’s worse right before decannulation. If you decannulate somebody they sound better even with the valves and all those kind of things. And in general a supraglottic phonation is worse than a regular phonation. So there was a thing on which outcome measurement should we measure. If you look to your right and your left you can see 10 of these authors. Okay. This is this group that was talking about it. And in that the presence or absence of a supraglottic voice and whether or not there was a vocal cord palsy were the only two things that were agreed upon of another 70 or more than 70 measures that we said oh we need to have these. Now clinical voice evaluation came near consensus but it didn’t make it. And voice quality, voice analysis, phonation time, all those things didn’t make it in the Delphi. So we internally don’t value speech as much as we could. This is another thing from Dr. Elikon and what he said was much like Paul Wilgings said hey if you do a fees it may change what you do in your surgery. What he says is you should do a voice evaluation because it may change what you do in your surgery. And in his practice which I’ll admit is a more voice oriented practice, a third of the or two thirds of the patients actually had some benefit or some change in the way that they were managed. Half of those were in the surgery that was chosen and half of them was in the speech therapy. So what are the principles? Avoid injuries if you can. So try not to burn bridges for the generation that is following you said the 65 year old. I want to make sure that what I do is okay but I don’t want it to change the next person’s ability to be able to be successful. So an obvious example of this is the posterior cricoid split which Steve Gray described initially as an open procedure but once it had evolved to an endoscopic procedure and not coming through the cords you could do almost anything you wanted in the back without screwing up the joint, without screwing up the tension, without screwing up the nerves. So there was trying to stay along those lines, trachea resection or slides do obviously avoid that area as long as we preserve the nerve. Cord lateralizations and various erytenoidectomies, all of them are based on taking some structure and scarring it into a place where it didn’t belong. And then similarly, Larenga fissure, I was taught to be really very, very, very specific about exactly where the fissure went and about the reconstruction. That’s the place I was supposed to send the most of my time. So what is a prototypical aero digested patient who would not have been in the cleft clinic or would not have been in the trach clinic? It’s the kid with the TE fissula who ends up with a cord palsy. So I said, okay, well what’s the literature tell us about that? Well what it says is in the otolaryngology literature this first appeared and the incidence was about 5%. Later on there have been a couple of studies in the tens that reported vocal cord palsy in the 2 to 1% range. Another study that reported it at 11% range, but the best studies are really broader cardiac studies. There are plenty of cardiac surgery studies where they say we’re going to look before and after. Now you can’t look before in the kid who’s intubated in the ICU, so we’re excluding those patients. But these numbers are really for the patients who had enough of a concern that the otolaryngologist got called afterwards and came to see them. So you can just guarantee that these numbers are actually higher than what you see here. And one of the nice things is that the type Cs are the most common, so that’s where you get most of the palsies. But the H fistulas, which we’re often more involved with, are more likely to produce this. So unilateral, bilateral cord palsy, I’m going to move through this in time. So the primary voice procedures, speech therapy is a huge, huge surgical procedure. It just is. And it’s not like VNE where if the palate doesn’t make it to the back of the pharynx, it’s not going to work. Speech therapists can almost always get you someplace closer to effective speech. There are plenty of medialization procedures, posterior cricoid reduction, reinnervation, either selective or non-selective. For those patients that as part of their TE fistula management and their way of reconstruction had a stenosis, they could have had an anterior graft, and so bringing the commissure back together. And then one of the things that we don’t do in the United States, or at least I don’t know of anybody who’s doing it in the United States, is vocal cord pacing in kids. I actually saw it in an Espo a couple of years ago. It’s fantastic. It is just amazing to see the cords snapping together and snapping apart. I’m worried that if I do too much in a written oidectomy and pulling and lateraling and all those kind of things, that technology is not going to be available to them in the future. So I can’t say that it’s something that is truly meaningful, but the engineer in me says it is something that’s truly meaningful. And then I’m going to pass over this one, but it’s just you take a look at the literature. This is both speech and swallowing, but in infants with unilateral cord palsy after surgery, you can do tiny injections, and I think it certainly helps swallow and it could help voice. And then the last thing is I knew that the group ahead of me was going to be doing management of decannulation, which meant that they were going to be talking about CAPS. Listen to them. Because if you look at children, the parents are most concerned, or parents of children are most concerned about a lethal event. Children are most concerned about communication and belonging. And once you’ve capped a kid or you have a passe or a trach or you choose your valve of choice, once they can speak, they will be able to integrate in a really superior way. And I’m two-thirds of the way toward decannulation when I’ve got a kid who’s participating fully in school. He’s not swimming, but he’s doing pretty much everything else. Thank you very much. [applause] >> Thanks so much for the invitation to speak on this topic. Although this says swallowing voice and the altarpediatric area, I’m really focusing more on voice today because it’s sort of the forgotten child and the aero group. So thank you for the opportunity. I work in the aerodigestive clinic, also in the cleft and craniofacial clinics and the voice clinics. And so my lens is really on the outpatient side. I will be talking about the voice-related assessments that we complete, what interventions that we have that are available, both direct voice therapy as well as compensatory strategies, and then focusing on quality of life. And then with the case study, I know I said I was going to focus more on voice, but she also has some swallowing concerns that are included in that. I don’t need to repeat what we already know, but we know that there’s a risk of voice and swallowing changes in the context of these interventions for kids with altered airway diagnoses. And as a young clinician studying in graduate school, I remember a professor saying that breathing always wins, but hopefully we can strike a balance where we have some functionality of voice and swallowing as well. For the kids that have a tracheostomy, the impact on voice is present. If they have no ability to move any airflow through their vocal tract, then they are oftentimes totally aphonic, if not severely dysphonic. When a person on a trach also has a vent and they’re a verbal communicator or even in a pre-verbal stage of communication development, they have to learn how to pair their voicing with their mechanical breath. These place these kids at a higher risk for just broad communication delays and disorders. And like I said, for the patient who has a trach but is severely dysphonic or aphonic, it can present a significant safety risk for meeting basic needs and just asking for help. When we’re listening to these disordered voices, they are distracting and sometimes can be severely dysphonic. The vibratory source and the phonatory patterns are variable. We see a lot of kids who utilize compensatory strategies of accessing their supraglottic structures for some way to get some vibration somewhere in their vocal tract. Sometimes they can still access some vibration through the true vocal folds, but if the vocal folds are not on the same vertical plane, if there’s scarring and tethering of structures in their larynx, and then also they’re kind of using supraglottic structures with the true vocal folds, you get a pretty severely dysphonic sound, which can significantly impact their quality of life. On the right, you can see this long list of descriptive terms that we sometimes use to describe voices. Amongst the speech pathologists in our group who are evaluating voice and listening to voices, we oftentimes will listen to voices together. It’s important for us to have some consensus about what we’re hearing and how we’re describing things so that we can be more consistent in terms of our clinical outcome measures and making sure, like, if I see a patient and then someone else sees the patient a year later, are we using the same language? There’s a few audio files here. This first one, you can play the yellow one first. It’s a young adult with a trachin event. Perhaps the yellow audio file could be accessed. While they’re figuring that out, you can hear this young adult working hard to coordinate. [ Video playing ] And you can stop the audio. [ Video playing ] You’re getting a great view. Anyway, so he really has to work hard to coordinate his voice with a mechanical breath. He has a progressive neurological disease, so his trachin event are not going anywhere. He has a strong goal to be a podcaster and a radio broadcaster, and he’s working hard with speech therapy to maximize and optimize his ability to communicate and be understood. We don’t need to go through all of these, but perhaps the red one you could play. [ Video playing ] And you can stop the audio there. So you can hear he sounds breathy. He has some strain. He’s speaking during inhalation as well as exhalation just for efficiency of voice because he’s losing quite a lot of airflow as he’s speaking. So we can listen to these voices. We can describe them, but until we really visualize their airway, we don’t know why. So that’s — the auditory portion of our assessment is important, but we also need to see. So if we could advance the slide, I’m just having trouble advancing. Oh, gosh. Okay. So, as I said, we paired with the ENT, we obtained flexible laryngoscopy with video stroboscopy if possible. Sometimes there are no structures that are really vibrating normally. The true vocal folds may not be vibrating normally enough to get stroboscopy completed, but we attempt that if possible. We are using the KP for kids that can repeat those sentences that you started to hear in that last recording. And for kids who are in a pre-verbal stage of development or non-verbal but vocalizing, we use the GRBIS scale as a more general tool to describe what we’re hearing. We’re observing their breathing pattern with phonation so that we can see, like, is this a functional pattern? Are they compensating well or are they using accessory muscles to breathe, like, a lot of tension, muscle tension in their upper chest, neck, shoulders? We are obtaining some basic acoustic and aerodynamic measures, primarily fundamental frequency, intensity of voice, maximum phonation time. And we do use parent-reported outcome measures, including the PVHI and the pediatric voice-related quality of life. But part of the assessment really, for me, is like, can I elicit a different pattern or is what they’re doing the best that they can do and we can’t change it? So the stimulability testing is both important during the voice assessment with the KP, but also during imaging if possible. And then kids are undergoing airway surgeries. Their interventions really create a moving target with their voice. We’re trying to track outcomes, but again, we’re trying to really see and understand that what changes to the laryngeal structure and function and what’s the impact and how can we determine what’s a compensatory strategy that’s actually benefiting them well versus what’s a behavioral intervention that we can offer to maximize and optimize their voice. So thinking of those acute stages of airway interventions with a patient in the hospital, maybe severe swelling and no access to voice, maybe a stent is in place, they have no access to voice, we worry about safety and being able to alert for help. You can use a Big Mac, which is just a single button switch, and you can pre-record a word or a message that can help them access help if there’s not a nurse or an adult in the room to assist them. When kids are more out in the world, you can consider like a wire.