Grand Rounds: Pediatric Dysphagia Due to Anatomic & Neurologic Etiologies

Transcription

1 Joan C. Arvedson, PhD, BC-NCD, BRS-S Children's Hospital of Wisconsin Milwaukee Department of Pediatrics, Medical College of Wisconsin Maureen A. Lefton-Greif, PhD, CCC/SLP, BRS-S Johns Hopkins Medical Institutions Department of Pediatrics Grand Rounds: Pediatric Dysphagia Due to Anatomic & Neurologic Etiologies The Annual Meeting of the American Speech-Language-Hearing Association Chicago, Il November 21, 2008

2 Educational Objectives: Participants will be able to ID factors essential to the evaluation and treatment of infants and children with dysphagia List 3 reasons for completing a VFSS Discuss 3 possible reasons for late recovery of swallowing in TBI

3 Evidence Based Practice (ASHA, 2005: Accessed 10/31/08:

4 Evidence Based Practice With limited evidence, need to rely on Evidence from: knowledge of normal and abnormal development knowledge of physiology Staying within scope of practice Adhering to the Code of ethics (ASHA, 2005: Accessed 10/31/08:

5 Actions Level of Intervention Mx & Tx Decisionmaking Guidelines Early detection, prevention "Normalization, support "optimal" develop. progression Mx / tx of deficits - specific swallowing phases or feeding Decrease patterns risk of aspiration Minimize risk of nutrition compromise Maximize growth & development Facilitate appropriate child/caregiver interactions Basic Management Principles Maintain cardiopulmonary stability Maintain nutritional stability Use developmentally appropriate Whole child approach(e.g., comfort, enjoyment)

6 Case: R.M. 3 month, ex- 38 wk female Mom in methadone program during pregnancy 3 wk hx of fever rhinorrhea, & nasal congestion w/o cough

7 Case: R.M. Trouble feeding Decreased PO intake Weight loss Gradual onset of NPR and gagging w/ feeds

8 R.M.: 3 month male Tentative dx of retropharyngeal infection Being treated with antibiotics - phlegmon

9 Retropharyngeal Space is limited above by the base of the skull, while below it extends behind the esophagus into the posterior mediastinal cavity of the thorax RPM s rare, but may be life threatening -Dodds et al,1988

10 phlegmon /phleg mon/ (fleg mon) diffuse inflammation of the soft or connective tissue due to infection The American Heritage Medical Dictionary Copyright 2007, 2004 by Houghton Mifflin Company. Published by Houghton Mifflin Company

11 Craig + Schunk, 2003; Al-Sabha et.al., 2004 Retropharyngeal Masses (RPM s): Primary Causes Children (75% younger than 5 yrs): Infection Infection from nasopharynx, paranasal sinsus, or middle ear extends to lymph nodes With increasing age, atrophy of regional lymph nodes Adults: Trauma Foreign body ingestions Complication of procedures Also, immunocompormised state

12 RPM s: Variable Presentations Fever Lethargy Irritability Neck rigidity, torticollis, rigidity Airway obstruction Stridor, tachynpea, or apnea Dysphagia Poor oral feeding 36% Drooling Feeding refusal Craig + Schunk, 2003

13 RPM s: Why Variable Presentations? Mass effect of inflamed tissue or abscess on surrounding structures Direct involvement of surrounding structures with the infectious process

14 RPM s: Treatment Airway is primary concern Treatment modalities range from antibiotics to surgery Complications from deep neck infections reported to range from 7.5 to 43% (Daya et al, 2005)

15 R.M.: 3 month male Tentative dx of retropharyngeal infection Being treated with antibiotics - phlegmon UGI no TEF, NPR SLP consult for feeding / swallowing evaluation

16 R.M.: SLP - Feeding / swallowing consult What questions do you ask or actions do you take? VFSS? UGI? Prognosis D/C disposition

17 R.M. What questions do you ask / actions do you take short vs. long term? Complete VFSS? Reasons and when? Nutrition and safety of feeding? Oral feedings? When? How / amount? O-M therapy?

18 R.M. What if patient does not respond to antibiotics and needs to undergo excision of mass What questions do you ask / actions do you take? VFSS? When? Oral feedings? When? How / amount? O-M therapy

19 R.M. Pt to be transferred to step-down care facility to complete 10 day course of antibiotics

20 R.M. Assume no surgery is indicated What questions do you ask / actions do you take VFSS? When? Oral feedings? When? How / amount? O-M therapy?

21 R.M days later Finished antibiotics MD won t start feeding w/o VFSS Request for re-eval to assist with management / discharge plans

22 R.M days later Resolution after finishing antibiotics vs. excision of mass? Compensation Decompensation Breathing more easily Less nasal congestion Oral feeding has improved, still problems VFSS????

23 Interpretation: Primary issues Has swallowing changed? If yes, improved or worsened? What appears to count for change or nochange? Sampling? Is the study consistent with the underlying etiology? What are your recommendations?

24 Route of feeding Management: R.M. Feeding recommendations Liquid characteristics Timing

25 Management: R.M. Therapy recommendations Additional recommendations Plans for follow-up

26 R.M.: After VFSS # 2 Interpretations Changes since last VFSS? Sampling? Consistent with underlying dx? Recommendations Oral feedings? When? How / amount? O-M therapy? VFSS? When?

27 Route of feeding Management: R.M. Feeding recommendations Liquid characteristics Timing

28 Management: R.M. Therapy recommendations Additional recommendations Plans for follow-up

29 Adapted from: Arvedson & Lefton-Greif, 1988 This case illustrates that a VFSS may be indicated/repeated when. Oropharyngeal dysphagia is suspected and VFSS findings may Assist with diagnostic decisions Influence management plan Demonstrate changes in oropharyngeal function that influence either diagnosis or management

30 VFSS findings must always be interpreted within the context of Actions Level of Intervention Mx & Tx Decisionmaking Guidelines Basic Management Principles

31 References Al Sabah, B., Bin, S. H., Hagr, A., Choi-Rosen, J., Manoukian, J. J., & Tewfik, T. L. (2004b). Retropharyngeal abscess in children: 10-year study. J Otolaryngol., 33, Al Sabah, B., Bin, S. H., Hagr, A., Choi-Rosen, J., Manoukian, J. J., & Tewfik, T. L. (2004a). Retropharyngeal abscess in children: 10-year study. J Otolaryngol., 33, American Speech-Language- Hearing Association (2007). Scope of Practice in Speech-Language Pathology [Score of practice]. Available from American Speech-Language-Hearing Association (1994). Code of ethics. American Speech- Language-Hearing Association, 36, 1-2. Arvedson, J. C. & Lefton-Greif, M. A. (1998). Pediatric Videofluoroscopic Swallow Studies: A Professional Manual with Caregiver Handouts. San Antonio: Communication Skill Builders. ASHA, 2005: Accessed 10/31/08: Craig, F. W. & Schunk, J. E. (2003). Retropharyngeal Abscess in Children: Clinical Presentation, Utility of Imaging, and Current Management. Pediatrics, 111, Daya, H., Lo, S., Papsin, B. C., Zachariasova, A., Murray, H., Pirie, J. et al. (2005). Retropharyngeal and parapharyngeal infections in children: the Toronto experience. International Journal of Pediatric Otorhinolaryngology, 69, Dodds, B. & Maniglia, A. J. (1988). Peritonsillar and neck abscesses in the pediatric age group. Laryngoscope, 98,