Management of Swallowing in Adults Undergoing Laryngotracheal Resection and Reconstruction

Holman, Allison; Clunie, Gemma; Roe, Justin; Goldsmith, Tessa

doi:10.1044/persp3.sig13.113

Cited by 2 publications

(7 citation statements)

References 22 publications

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“…Existing studies on dysphagia as a primary outcome of LTS and airway reconstruction have explored data such as duration of tube feeding post-reconstruction [ 16 ] and a clinician-rated scale to assess changes in swallowing function before and after surgery [ 11 ]. The clinical presentation and best practice management of dysphagia in this population has been reported in both the adult and paediatric literature [ 17 , 18 ]. There are no adult studies that have focussed on the biomechanical mechanism of dysphagia as a result of LTS or airway surgeries, however clinical experience shows that for the majority of patients significant dysphagia is short-term, and is related to a combination of reduced swallow efficiency and safety [ 17 ].…”

Section: Introductionmentioning

confidence: 99%

Not Just Dyspnoea: Swallowing as a Concern for Adults with Laryngotracheal Stenosis Undergoing Airway Reconstruction

et al. 2021

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Acquired laryngotracheal stenosis (LTS) is a rare condition causing dyspnea and stridor. Patients often require multiple surgical procedures with no guarantee of a definitive outcome. Difficulty swallowing is a recognised problem associated with LTS and the reconstructive surgeries required to manage the condition. The breathlessness patient’s experience impacts on swallowing, and the vulnerable structures of the larynx are implicated during complex surgeries. This leads to dysphagia post-surgery, with some patients experiencing more chronic symptoms depending on the biomechanical impact of the surgery, or a pre-existing dysphagia. Despite this there is limited observational research about the dysphagia associated with LTS, with no exploration of the patient experience. Our aim was to investigate patient experience of living with LTS focussing on dysphagia in order to guide clinical practice. A qualitative study was completed using focus groups and semi-structured interviews with 24 patients who have had reconstructive surgery for LTS. Thematic analysis was used to identify three over-arching themes: The Physical Journey, The Emotional Journey and The Medical Journey. Key sub-themes included the importance of self-management and control, presence of symptoms, benefits of therapy, living with a life-long condition, fear and anxiety, autonomy, medicalisation of normal processes and the dichotomy between staff expertise and complacency. Swallowing was connected to all themes. The results are reviewed with consideration of the wider literature of lived experience particularly in relation to other chronic conditions and those that carry a high symptom burden such as head and neck cancer. Future clinical and research recommendations have been made. Akin to other clinical groups, adults with LTS are keen that management of their swallowing is person-centred and holistic.

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Section: Introductionmentioning

confidence: 99%

Not Just Dyspnoea: Swallowing as a Concern for Adults with Laryngotracheal Stenosis Undergoing Airway Reconstruction

et al. 2021

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“…This lack of consensus has resulted in considerable variation in practice with respect to nutritional management of the newly reconstructed airway, specifically the duration of tube feeding, timing and nature of swallow assessment and length of hospital stay. 6 A clear understanding of preoperative swallow status based upon instrumental evaluation (ie VFS and Fibreoptic Endoscopic Evaluation of Swallow, [FEES]) with validated scoring systems may support appropriate patient selection and preparation for airway reconstruction, as well as helping to predict the likely degree and duration of postoperative dysphagia. This is of critical importance because it is recognised that underlying aspiration pre-disposes to reconstruction failure and may deteriorate with surgery such that significant chronic lung damage ensues.…”

Section: Instrumental Swallow Assessment Around the Time Of Airway Reconstructionmentioning

confidence: 99%

“…1 If an oesophageal issue is suspected or the degree of aspiration on FEES is in doubt, a VFS may be performed if it is likely to change management. The treatment of any identified dysphagia includes therapeutic manoeuvres, dietary modifications, interim tube feeding and swallowing rehabilitation exercises as part of a regular review process to ensure progression, 6 with avoidance of nil by mouth status wherever possible. Such an approach is supported by our belief that oral intake and swallow rehabilitation are the major independent (and interrelated) factors influencing long-term swallowing outcomes in a mobile, independent and otherwise healthy patient cohort, whilst excessive caution risks further deterioration in function.…”

Section: Patient Evaluation and Treatmentmentioning

confidence: 99%

“…[3][4][5] For patients afflicted with LTS, long-term effects on voice and swallow are experienced both as a result of the underlying condition but also the attempts to treat it, often in the form of repeated endoscopic airway dilatations which precede more formal reconstructive surgery. [6][7][8] Impaired deglutition can result in profound morbidity or death as a result of tube feeding dependency and recurrent aspiration, the aetiology of which is multifactorial and includes postoperative and post-radiotherapy oedema and fibrosis, reduced laryngeal sensation and hyolaryngeal excursion, intra-operative supra-and infra-hyoid muscle release, the presence of an airway stent, cricoarytenoid joint fixation, the sequelae of laryngofissure and recurrent laryngeal nerve injury affecting vocal cord adduction and upper oesophageal sphincter opening. 2,6…”

Section: Introductionmentioning

confidence: 99%

“…[6][7][8] Impaired deglutition can result in profound morbidity or death as a result of tube feeding dependency and recurrent aspiration, the aetiology of which is multifactorial and includes postoperative and post-radiotherapy oedema and fibrosis, reduced laryngeal sensation and hyolaryngeal excursion, intra-operative supra-and infra-hyoid muscle release, the presence of an airway stent, cricoarytenoid joint fixation, the sequelae of laryngofissure and recurrent laryngeal nerve injury affecting vocal cord adduction and upper oesophageal sphincter opening. 2,6…”

Section: Introductionmentioning

confidence: 99%

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Perioperative instrumental swallowing evaluation in adult airway reconstruction: A retrospective observational cohort study

Haywood

Lovell

Roe

et al. 2021

Clinical Otolaryngology

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Objectives: Airway reconstruction for laryngotracheal stenosis (LTS) encompasses several procedures. Dysphagia is a well-recognised sequela of LTS and airway surgery, however studies have employed mostly non-validated assessments post-operatively in small, heterogenous samples, perpetuating uncertainty around the contributions of LTS and its management to impaired deglutition. Consequently, considerable variation in LTS perioperative nutritional management exists. Our objective was to characterise baseline and post-operative dysphagia with instrumental assessment in an LTS cohort undergoing airway reconstruction and provide a gold-standard management framework for its management. Design, setting, participants and main outcome measures: We performed a retrospective cohort study of adult airway reconstruction procedures from 2016-2020 at our quaternary centre. Patient background, LTS aetiology, procedure type, tube feeding duration, length of stay and serial Functional Oral Intake Scale (FOIS) and International Dysphagia Diet Standardisation Initiative (IDDSI) scores were noted. Baseline, post-operative day one and post-stent removal Fibreoptic Endoscopic Evaluation of Swallow (FEES) generated Penetration Aspiration Scale (PAS) scores.Results: Forty-four patients underwent forty-six reconstructions. Baseline incidence of penetration-aspiration was considerably higher than the general population and worsened in the immediate post-operative period, however FOIS and PAS scores generally returned to baseline by discharge. Post-operative FOIS correlated negatively with tracheostomy or airway stent placement. At discharge, 80% tolerated soft or normal diet and 93% were feeding tube independent. Conclusions:We present the largest adult airway reconstruction cohort with instrumental swallow assessment perioperatively. LTS patients have a higher incidence of underlying dysphagia but swallowing tends to return to baseline with appropriate postoperative rehabilitation. Such practice may avoid the complications, costs and morbidity of prolonged nutritional support.

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Management of Swallowing in Adults Undergoing Laryngotracheal Resection and Reconstruction

Cited by 2 publications

References 22 publications

Not Just Dyspnoea: Swallowing as a Concern for Adults with Laryngotracheal Stenosis Undergoing Airway Reconstruction

Not Just Dyspnoea: Swallowing as a Concern for Adults with Laryngotracheal Stenosis Undergoing Airway Reconstruction

Perioperative instrumental swallowing evaluation in adult airway reconstruction: A retrospective observational cohort study

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