Center of reference for neurogenic swallowing disorders and tracheostomy tube management

Dysphagia is characterised by the disability to deliver foods, liquids and saliva from mouth to stomach in a sufficiently swift and secure way. The physiological deglutition act, in substantial parts controlled by neural reflex circuits, represents a complex process requiring a precise interplay of all involved sequences within a concise fraction of time. Detailed clinical examination and specific instrument-based and device-controlled examination methods likewise allow for an authentic evaluation of the swallowing function. Hence, in the individual therapy setting an optimal treatment adapted to the single patient´s necessities is realised. The concept of treatment is focused on the core principles restitution of physiological processes, adjustment by acquisition of alternative strategies and modification of foodstuffs and liquids.

Symptoms

Symptomatology is stretching across frequent incidents of choking on and coughing during food intake, perpetually clearing one´s throat and the sensation of having a lump in one´s throat, increased salivation, drooling, impaired gag reflex, to the point of acute and recurrent pneumonia due to aspiration of foreign matters.

Diagnosis

Underlying disease for dysphagia is basically diagnosed by performing a physical and neurological examination of the patient completed by imaging such as computed tomography (CT) and nuclear magnetic resonance (NMR). Supplementary specific examinations in order to assess type and severity of dysphagia, predominantly Functional Endoscopic Evaluation of Swallowing (FEES) and Video Fluoroscopy Swallowing Studies (VFSS) will be arranged (see below).

Clinical evaluation

Clinical assessment of dysphagia is executed by means of standardised protocols and validated rating scales. Analysis of cause, type and severity of dysphagia is found out by FEES and VFSS.

FEES (Functional Endoscopic Evaluation of Swallowing)

FEES is performed applying a flexible endoscope. Flexible endoscopes today are digital cameras, highly flexible, elongated and small in diameter in order to investigate body cavities some of them being endowed with a working channel to suck off secretions and to inject medications if needed (e.g. local anaesthetics, LA). FEES starts inserting the endoscope into one nostril, advancing it as far as the throat to gain optimal view onto anatomical structures such as soft palate, epiglottis and vocal cords. Upon valuation of actions the patient is requested to produce certain sounds or is requested to cough thus movements of the involved structures in doing so may be judged. Performing swallowing trials the patient has to ingest various consistencies of substances and foods, e.g. puree, liquids, thickened liquids, semisolid and solid foods, in order to seize potential impairments in the course of deglutition.

Video-Fluoroscopy-Studies (VFSS)

Fluoroscopy is an x-ray based method of examination. Patients are supposed to swallow a specific contrast medium by which the physician is able to assess the full course of the swallowing process. In particular swift movements in mastication and deglutition may accurately be covered thus rendering diagnostic classification achievable. Frequently VFSS are utilised in addition to FEES.

"Therapeutic bronchoscopy” (Bronchoscopic removal of secretion and aspiration)

Bronchoscopy represents another type of endoscopy. A flexible endoscope invariably equipped with a working channel (see description at chapter "FEES”) is employed to assess bronchial system state and to remove secretions and potential foreign substances in case of bronchial mucoid impaction and unanticipated pulmonary aspiration in the course of neurogenic swallowing disorders. Patients who are designated for this procedure will be supplied with intravenously administered analgetics and sedatives as well as with locally applied nasal and intrabronchial anaesthetics; the endoscope is inserted via nose and via tracheostomy, respectively. If necessary a bronchoalveolar lavage (BAL) to efficiently clear the bronchial system as well as sample-taking for antimicrobial and antibiotic sensitivity testing may be added.

Treatment

Line of action in logopedics (speech therapy)

Functional treatment of deglutition (FTD) aims at acquiring safe and efficient swallowing in accordance with evidence based therapeutic strategies. A customised therapy program is drafted including the specific pathology of swallowing and the underlying disease together with the everyday situation of the patient. Reconstituting applications support neuromuscular function by utilising sensory stimulation (e.g. direct muscle stimulation, stimulation of the deglutition reflex trigger) in order to enable physiologic swallowing. Furthermore compensatory swallowing techniques (e.g. to master particular swallowing manoeuvres) and strategies of adaptation (e.g. modulation of consistencies of foods and liquids) are implemented. Overall objective is to achieve safe drinking and eating as soon as may be.