Problem-Solving Swallowing after Supraglottoplasty

Question from Jennifer SLP: I’m curious to know your thoughts and/or procedures for feeding evals post supraglottoplasty? Do you always do an MBS? Only when indicated? How soon after supraglottoplasty do you do an MBSS (if you do one)? What are your treatment plans/outpatient recommendations if they are not safe to PO? Thank you!

Answer:
It really depends on the infant’s/child’s history and co-morbidities, as of course each has a unique presentation and requires an individualized differential.

In general, when co-morbidities require a supraglottoplasty is recommended, there is typically an associated adverse effect on swallowing physiology being appreciated pre-op. The post-op swallowing physiology, however, is not always improved. It is sometimes more problematic after the supraglottoplasty, which can actually worsen airway protection and further alter physiology.

The related co-morbidities (e.g., prematurity, sensory-motor issues etc.) and altered pre-op system function (GI, respiratory, neuro etc.) will further affect post-op results.

Perhaps work with the ENT/surgeon/attending as to timing of small PO trial with ST to get the infant/child ready for radiology and then objectively determine any adverse effects along the swallow pathway present post-op, or any impairment/alteration that was appreciated pre-op and persists post-op. Sometimes surgeons assume the supraglottoplasty will “fix” swallowing and that may not be the case, in my experience.

Then here is the updated information from Jennifer, SLP:
This has been really helpful. I’ve been working with the ENT, he doesn’t have an idea of when exactly she will be “healed” from her procedure, but we both agree she may need more time. Here is the case in full:

Ex 36 weeker, brought to hospital at 1 week old for stridor. Found to have severe laryngomalacia – obstructive with the arytenoids collapsing in the airway. Made NPO because (Thank you Catherine – I’ve been to your course!) she couldn’t breathe – so she couldn’t eat. Trialed taste trials, but continued to have increased work of breathing and desats were significant. Had a supraglottalplasty on 9/5/16. Trailed taste trials again on 9/8/16 with little to no stridor but multiple swallows (x5) with each bolus and increased congestion with trials. Continued with taste trials for a week. Medical team pushed for a MBSS, they were worried we were being too conservative as a baby post supraglottalplasty may still continue to have noisy feeding. In the MBSS the baby aspirated on thin and nectar consistencies, even using a preemie nipple, 1-suck pacing, sidelying, 1/2 filled nipple. She had really poor swallow function observed in the MBSS – overall weak sluggish movements, multiple swallows, aspiration on primary swallows and residuals. We are continuing to trial tastes with her conservatively – but no progress thus far. She is now term, and the ENT believes she probably had a poor swallow and once they lasered away the tissue covering her airway, her swallow dysfunction was more obvious. She has no other known co-morbidities.

I’m just wondering when we need to make decisions about her long-term plan? Do we give her more time? Also, has anyone worked with a baby like this and have any successful treatment plans? Thank you so much.

My response:
Thanks for more information. Are there other less obvious co-morbidities, as this sounds atypical for a late preterm (36 weeks GA) with an “isolated” laryngomalacia. What was the etiology (or etiologies) for the aspiration? Were the events silent? Was there any other form of bolus mis-direction? We know she otherwise has no known co-morbdities, but is she presenting normally (neuro, postural tone/movement patterns, oral-pharyngeal reflexes, saliva swallows)? I suspect not, based on what you have told us.

I agree with the ENT that the infant probably had swallowing dysfunction pre-op and once they lasered away the tissue covering her airway, I took away “protection for the airway” and her primary swallowing dysfunction “declared itself”. EER/LPR may be playing a part as it is commonly associated with both LM and silent aspiration according to the research. Wonder if ENT saw evidence of EER/LPR when he scoped her? Is she being treated for EER/LPR? Could there be aspiration both from below and above that might be contributing?

Since this presentation is atypical for a late preterm with LM –are they doing a further work up to help elucidate the bigger picture likely affecting the integrity of her swallow? It is perhaps a separate issue from the original need for a supraglottoplasty and that may help to guide prognosis and plan.

Given the nature of the swallowing impairment you describe, and the interventions so thoughtfully trialed in radiology, I suspect this is not going to resolve in the near future. Keep us posted on the results of a further workup as that should help decision-making. Continued pacifier dips and positive oral-sensory-motor input will be important to keep her system primed for return to PO feeding, as co-morbidities and safety permit.

Erika Lee, one of my SLP colleagues from Oklahoma, reminds us that “the purpose of supraglottoplasty is to improve the infant’s breathing; and if that is accomplished, then feeding usually gets better. The supraglottoplasty usually delivers benefits immediately; but then the effects get better over time as the surgery site heals (especially if a laser was used). Surgeons typically assess the entire airway and palpate the interarytenoid space to assure that there is no laryngeal cleft.” The just published manuscript is attached.

I hope this is helpful.

Please click below for the manuscript…

Supraglottoplasty Otolaryngol Head Neck Surg 2011 (818-22)

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