vagal nerve injuries and dysphagia barkmeier-kraemer final
TRANSCRIPT
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Julie Barkmeier‐Kraemer, PhD, CCC‐SLP
Julie Barkmeier‐Kraemer, Ph.D., CCC‐SLP, ASHAF
Professor, Division of Otolaryngology
Clinic Director, Voice Disorders Center
Email: [email protected]
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Disclosures
Financial
Employed by the University of Utah
Funded by the NIH to conduct research relevant to information in this presentation (R01DC011311)
Receives royalties from Plural Publishing for the workbook, “Dysphagia Assessment and Treatment Planning Workbook: A Team Approach”
ArSHA speaker honorarium
Non‐Financial
Member of the Dysphagia Research Society (DRS)
Member of ASHA and ASHA’s SIG 3 and 13
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Learning ObjectivesUpon completion of this lecture, participants will be able to:
1. Identify and describe signs and symptoms of vagal nerve injury evidence during a clinical dysphagia examination, and
2. Identify and describe visual perceptual and quantitative measures associated with the pathophysiology of dysphagia in those with vagal nerve injury.
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Overview of the vagus nerve (CN X)
Respiratory
Upper airway
Lower airway
Cardiopulmonary
Heart rate
Blood pressure
Deglutition
Oropharyngeal
Esophageal
Digestion
Voice/Resonance
Gut‐Brain Connection
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Clinical consideration of vagus n. branches
Pharyngeal plexus
Superior laryngeal nerve
External branch
Internal branch
Recurrent laryngeal nerve
Cardiac branch
Pulmonary plexus
Esophageal plexus
Image taken from: https://medical-dictionary.thefreedictionary.com/_/viewer.aspx?path=MosbyMD&name=vagus-nerve.jpg&url=https%3A%2F%2Fmedical-dictionary.thefreedictionary.com%2Fvagus%2Bnerve 6
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Focus of this presentation
Vagus nerve lesions
Identifying and evaluating clinical signs & symptoms
Using evidence to guide treatment planning
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What is “Normal”?
Pharyngeal Stage Events
Transit of bolus through the pharynx
1. Closure of the velopharyngeal port
2. Pharyngeal shortening and expansion ahead of the bolus
3. Constriction of pharynx behind the bolus
4. Closure and anterio‐superior movement of the airway
5. Relaxation and opening of the upper esophageal sphincter
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The Afferent System
The signal to trigger the pharyngeal swallow is through:
CN IX (glossopharyngeal)
CN X, internal branch of the SLN
Afferent trigger of the Oropharyngeal Swallow
Swallowing is triggered from two general regions:
1. Mucosa of the BOT and anterior/posterior faucialpillars (CN IX)
2. Mucosa of the oro‐ and laryngopharynx (internal branch of the SLN (iSLN) and CN IX fibers via pharyngeal br of CN X)
Research suggests the iSLN as the strongest trigger of the two
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The Efferent System The motor neurons involved in the oropharyngeal swallow include motor nuclei for CNs:
Tongue musculature (intrinsic and extrinsic) via Hypoglossal Nucleus (CN XII)
Soft Palate, Pharyngeal Constrictors, and Laryngeal musculature via the Nucleus Ambiguus nucleus (CN IX & X)
Slide shared with permission from: Jones, C, Ciucci, MR, & McCulloch, TM. High Resolution Manometry in the Management of Dysphagia. Presented at AAO‐HNS, September, 2013, Vancouver.
Slide shared with permission from: Jones, C, Ciucci, MR, & McCulloch, TM. High Resolution Manometry in the Management of Dysphagia. Presented at AAO‐HNS, September, 2013, Vancouver.
Combined HRM/Videofluoroscopy
Slide shared with permission from: Jones, C, Ciucci, MR, & McCulloch, TM. High Resolution Manometry in the Management of Dysphagia. Presented at AAO‐HNS, September, 2013, Vancouver.
VFE and Manometry Sequence
Adapted with permission from: Jones, C, Ciucci, MR, & McCulloch, TM. High Resolution Manometry in the Management of Dysphagia. Presented at AAO‐HNS, September, 2013, Vancouver.
Nasopharynx
Oropharynx
Laryngopharynx
Esophagus
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The bolus passes through the upper esophageal sphincter (UES)
Sequential esophageal muscular action propels the bolus through and into the stomach
Esophageal Stage Two high pressure zones prevent backflow of food:
UPPER esophageal sphincter (UES)
LOWER esophageal sphincter (LES)
No clear boundary distinction
Sphincteric muscles with tonic contraction at rest – relax during the swallow
High pressure zones
EFFERENT
Motor innervation to the muscles and glands (CN X)
Esophageal innervation
Perstaltic contraction pushes the bolus through the esophagus
Symmetrical contraction/relaxation of a muscular tube that propagates in a wave down the tube
Esophageal wave travels at 4 cm/sec
Involuntary response to pharyngeal swallow
Esophageal Peristalsis
AFFERENT Vagal (CN X) and spinal (C1 – T9)
Pain, discomfort, mechanical, thermo‐, and chemosensationinformation
Referred sensation = perception of food stuck in the throat or a lump in the throat referred from esophagus
Esophageal innervation
Vagal Contributions to Deglutition Motor contribution to:
Velopharyngeal valve
Palatal‐lingual valve
Pharyngeal swallow coordination
Respiratory/Swallow Coordination
Airway Protection
UES function
Esophageal transport
LES relaxation
Digestion
Sensory contribution to:
Initiation of the swallow
Sensation of bolus clearance from the pharynx and esophagus (including airway entry and cough trigger)
Digestion‐related sensationImage taken from: http://www.edoctoronline.com/medical-atlas.asp?c=4&id=21927 24
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Impaired pharyngeal swallow Vagal injuries contributing to dysphagia
Velopharyngeal function
Oropharyngeal swallow
Airway protection
Esophageal function
UES
Smooth muscle
LES
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Problem‐solving cases
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Unilateral vocal fold paralysis and Dysphagia
Anticipated pathophysiology:
Recurrent Laryngeal Nerve injury
Weak or impaired closure of the vocal folds during the swallow
Aspiration (particularly liquids) during laryngeal vestibule closure (LVC)
Reduced or delayed response to aspiration (assuming intact opposite nerve)
Superior Laryngeal Nerve injury Reduced pitch range and laryngeal “twist” during upward pitch glide
Inferior constrictor muscle weakness
Reduced sensation to laryngeal penetration/aspiration
Figure taken from Campbell et al, 2013
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Unilateral vocal fold paralysis and Dysphagia
Considerations
Hyolaryngeal excursion
Airway safety during swallow
UES opening (biomechanical)
Bolus pharyngeal clearance
Degree of laryngeal denervation Laryngeal closure on other levels
Laryngopharyngeal sensory function
Pharyngeal constrictor involvement
Ability to compensate/adjust to impaired function
What we fear
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Case #1: Idiopathic UVP: Voice Evaluation
56 yo female patient chief complaints:
1. Sudden onset of impaired voice quality
Voice Handicap Index = 91/120
Reduced loudness
Increased vocal effort/strain
Odynophonia
2. Dyspnea/stridor with physical exertion (Dyspnea Index = 20/40)
3. 10‐year history of intermittent choking on food (EAT‐10 = 17/40)
1. Esophageal dilation 7‐8 yrs prior
2. Senses solid food sticking at suprasternal notch
3. No problem drinking liquids
Endoscopy:
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Case #1: Videofluoroscopy
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Investigation of unilateral RLN lesion on oral, tongue, and infrahyoid muscle physiology during the swallow
Showed pre‐ to post‐lesion changes in timing, duration, and amplitude of motor patterns in cranial nerve musculature
TAKE HOME POINT: Brainstem level sensorimotor reorganization of swallow physiology post‐RLN lesion results in functional swallowing
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How you define dysphagia matters
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Pneumonia Rate
6% of 415 (N = 25)
Aspiration Rate
Of 415 individuals with UVP, 61 completed MBS
23% aspirated (N = 14) Abnormal max pharyngeal constriction (p = .003)
Common: Delayed airway closure (62%), but unrelated to aspiration
Etiologies and aspiration
Iatrogenic (36%)
19% of entire etiology group (N = 26)
Skull base tumor (36%)
50% of entire etiology group (N = 10)
Timing of aspiration
Before/After LVC = 12/14
During LVC = 3
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Case #2: Post‐op right glomus tumor61 yo female patient chief complaints:
1. Impaired voicing that began pre‐op, but worsened post‐op (2 mos ago)
Voice Handicap Index = 41/120 (mild problem)
Difficulty projecting voice
2. Difficulty swallowing (DHI = 34/100)
Avoids meat and bread, but otherwise IDDSI 1‐8
Lost 15 pounds unintentionally since onset
Prolonged meals
3. Coughing spells (Leicester Cough Quest. = 15.14/21)
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Case #2 Videofluoroscopy
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Case #2: Treatment PlanOur team’s plan:
Swallow strategies:
Aspiration precautions
Alternate food with sips of water to facilitate pharyngeal clearance
Tilt head toward stronger left side (based on MBS strategy testing)
Swallow exercises to improve hyolaryngeal excursion and engage pharyngeal musculature
Shaker
EMST exercises 41
Case #3: Case History19 yo female patient case intake:
1. Reported normal voice (VHI = 28/120)
2. Moderate to severe difficulty swallowing (DHI = 60/100) 3 month progressive onset of sensing smaller throat causing food to stick (e.g. potatoes, bread, and meat); feels the need to cough up; occasionally pills stick
Chokes on liquids at least once daily; Takes small bites of food and alternates with sips of water
Lost 18 pounds over past 3 months
Allergic to peanuts, eggs, mustard managed with benadryl
h/o GERD managed by pantoprazole for past 2 months
3. No cough (LCQ = 18/21), mild dyspnea (DI = 17/40) 42
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Case #3: Clinical EvaluationNormal Clinical Exam Findings:
1. Cranial nerve exam
2. Physical exam and palpation of anterior neck, larynx, jaw musculature
3. Volitional cough
4. Bite size, mastication, and swallows
Positive findings:
1. The patient reported the sensation of applesauce, mixed fruit cocktail, and cracker residue that cleared with water
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Case #3: MBS Findings
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What do you do with this patient?
Possible options: Consider vagal pathways
Reassurance
Education/Counseling
Refer to get professional counseling about their concerns
Refer to GI for evaluation of esophageal or digestive sources of sensations
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Case #3: Gastroenterology Assessment
Esophagram Clinical Findings
Esophageal dysmotility
Delayed gastric emptying with solid foods
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Additional Pharyngoesophageal Considerations
Structural/Functional abnormalities
Clinical Evaluation/Treatment
Gastroenterology team member
Imaging/Function testing
Medical/Surgical management
Otolaryngologist team member
Medical/surgical management of cervical esophageal issues
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Szabó & Szentkereszty, 2016. Surgical treatment of Zenker’s diverticulum, Is the open approach really outdated? Medical research archives, 2016, 4(8):1-10.
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Additional Pharyngoesophageal Considerations
The upper airway musculature
Clinical Evaluation/Treatment
Extrinsic and Supplemental laryngeal muscle palpation
Voice evaluation with laryngeal imaging
Laryngeal manipulation/circumlaryngealmassage
Voice therapy
49 Figure taken from: http://chiropracticprecision.com/vagus-nerve-important/
2007 50 yo female with a 25 pack/year smoking history
Subtotal large intestine colonectomy
T1 N0 M0 squamous cell carcinoma of the tongue with subsequent partial right‐sided glossectomy and neck dissection, no radiation treatment
Post‐operative SLP management of speech and swallowing difficulties
Patient quit smoking
2013 Onset of shortness of breath over 4 days ‐>ED visit
Head and neck surgeon did not identify recurrence of cancer or laryngeal pathology
MBS: Normal oropharyngeal function (EAT 10 = 27/40)
Esophagram: mid to distal esophageal retention of boluses observed with retrograde flow to PE segment
Dyspnea Index = 27/40 (mod‐severe) and LCQ = 5/21 (severe)
Breathing problem: Expiration > Inspiration
Fluctuation of voice preceded onset of throat clearing and coughing (VHI 73/120 total score)
G1, R1, B0, A0, S0‐1; MPT = 9 seconds
Case #42013 Laryngeal imaging 2013 MBS
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Progression of symptoms thereafter
2014
• Onset of globus sensation with swallowing difficulties
• Excessive spitting up of mucus that the patient coughs on with SOB
• Laryngeal palpation of moderate extrinsic laryngeal, neck, and strap muscle tension and pain
• Mildly rough voice quality
• Normal FEES, although right VF varix observed
• Recommended: SLP treatment for chronic cough and MTD
2015• MBS study by HNCa SLP team – Non‐obstructive CP bar and trace bolus retention in UES
2016
• GI: Unremarkable esophagram and EGD – referred for swallow evaluation
• Patient reported progression of daily gagging, regurgitation, and vomiting
• Wakens at 3 AM and spits and regurgitates copious amounts of mucus for 1 hour and then takes Zofran once able to calm symptoms before eating breakfast
• Laryngeal palpation triggered gagging and retching
• FEES anatomical views showed thickened cobblestone appearance to interarytenoid mucosa; laryngeal penetration of liquid bolus; intermittent gurgly voice quality; onset of gagging and expectoration of water bolus requiring cessation of FEES.
2019 GI management of GERD; two LES dilations without resolution of symptoms
Fall 2018, the patient experienced a small bowel obstruction caused by the scar tissue from prior colonectomy (2007).
The obstruction dissipated 3‐4 weeks prior
The patient continued to experience severe gagging, vomiting, and excessive mucus production worsened by
Ice or cold temperature foods
Breads and dry foods with thickened texture
Any dry foods (bread or pretzels)
Hot or spicy seasonings burn her throat
2019 (continued) Items that she can consume without difficulty:
Thin clear soups
Hot tea
Plain chicken ‐ requires prolonged mastication before swallowing
Plain Fish/shrimp ‐ well chewed
She notes slight relief from Zofran, but no other medications have helped.
Case #4: Laryngeal Imaging
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Cyclic Vomiting Syndrome (CVS)
Recommended amitriptyline to manage cyclic vomiting syndrome
This worked!!!
For ~1 week before drug tolerance developed
PCP gradually increased dosage to maximum
Figure taken from: Horn. Why is the neurobiology of nausea and vomiting so important? Appetite, 2008, 50(2-3):430-434.
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CASE 4: Auricular Nerve Stimulation
Auricular Nerve Stimulation for Cyclic Vomiting Syndrome (CVS)
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Summary: Vagal Nerve Assessment
1. Consideration of patient/caregiver‐based descriptions
Perceived anatomical location of problem
Description of the sensation/problem
2. Thorough sensorimotor cranial nerve evaluation to determine the “level of the lesion.”
3. Assessment tools and approaches that evaluate:
Anatomical integrity/function,
Airway‐swallow safety coordination and cough function,
Temporal and spatial patterns that impair function
4. Pathophysiology/Compensatory abilities ‐> Treatment
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Discussion
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References1. Campbell EO, Samlan RA, McMullen NT, Cook S, Smiley‐Jewell S, Barkmeier‐Kraemer J. Developmental changes in
the connective tissues of the porcine recurrent laryngeal nerve. J Anatomy, 2013, 625‐633.
2. DeLozier KR, Gould FDH, Ohlemacher J, Thexton AJ, German RZ. Impact of recurrent laryngeal nerve lesion on oropharyngeal muscle activity and sensorimotor integration in an infant pig model. J of Applied Physiology, 2018, 125(1): 159‐166.
3. DomerAS, Leonard R, Belafsky PC. Pharyngeal weakness and upper esophageal sphincter opening in patients with unilateral vocal fold immobility. Laryngoscope 2014;124(10):2371‐4 doi: 10.1002/lary.24779.
4. Francis DO, Sherman AE, Hovis KL, Bonnet K, Schlundt D, Garrett CG, Davies L. Life experience of patients with unilateral vocal fold paralysis, JAMA Otolaryngol Head Neck Surg, 2018, 144(5):433‐439.
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8. Ollivere B, Duce K, Rowlands G, Harrison P, O'Reilly BJ. Swallowing dysfunction in patients with unilateral vocal fold paralysis: aetiology and outcomes. J Laryngol Otol 2006;120(1):38‐41 doi: 10.1017/S0022215105003567.
9. Schiedermayer B, Kendall K, Stevens M, Barkmeier‐Kraemer JM. Prevalence, incidence, and characteristics of dysphagia in those with unilateral vocal fold paralysis. Laryngoscope 2020, 130(10):2397‐2404. doi:10.1002/lary.28401.
10. Stevens M, Schiedermayer B, Kendall K, Ou Z, Presson A, Barkmeier‐Kraemer J. Physiology of dysphagia in those with unilateral vocal fold immobility. Dysphagia, 2021 Mar 31. doi: 10.1007/s00455‐021‐10286‐4. Epub ahead of print.
11. Tsai MS, Yang YH, Liu CY, et al. Unilateral Vocal Fold Paralysis and Risk of Pneumonia: A Nationwide Population‐Based Cohort Study. Otolaryngol Head Neck Surg 2018;158(5):896‐903 doi: 10.1177/0194599818756285.
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