International Journal of Pediatric Otorhinolaryngology 124 (2019) 30–33

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Swallowing problems in children with a tracheostomy tube T

a a,∗ a b
Marloes Streppel , Laura L. Veder , Bas Pullens , Koen F.M. Joosten
a
Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
b
Department of Pediatrics, Pediatric Intensive Care Unit, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands

A R T I C LE I N FO A B S T R A C T

Keywords: Introduction: Swallowing problems in children with a tracheostomy tube seem to be a common problem, al-
Tracheostoma though exact prevalence is not known. The aim of this study is to identify the prevalence and type of swallowing
Tracheostomy tube problems in children with a tracheostomy tube.
Feeding difficulties Methods: We retrospectively included 44 children having a tracheostomy tube at Erasmus MC-Sophia Children's
Dysphagia
hospital. Assessment by a specialized speech and language therapist, the Modified Evans Blue Dye test, Video
Swallowing problems
Fluoroscopic Swallowing Study and a Fiber-optic Endoscopic Evaluation of Swallowing were reviewed with
Fibre-optic endoscopic evaluation of
swallowing regard to the different phases of swallowing, in particular signs of aspiration.
Videofluoroscopic evaluation Results: In our cohort, 31 (70%) children with a tracheostomy tube presented with problems in the oral and/or
Modified evans blue dye test the pharyngeal phase of swallowing. Overall 19 (43%) children aspirated.
Conclusions: The majority of children with a tracheostomy tube have swallowing problems in the different
swallowing phases with a high risk for aspiration.

1. Introduction oropharynx for respiration and swallowing. In children with marginal

Whereas in children with a tracheostomy tube the prevalence of
feeding and swallowing problems is not known, in the adult population
it is a common problem with reported percentages of 50%–87% [1–5].
In most tracheostomized children comorbidities are frequently present
and up to 70% of these children have severe feeding and swallowing
problems [6]. Children with feeding and swallowing problems are at
risk for malnutrition, developmental deficits, increased medical com-
plications, and stressful interactions with their caregivers [7]. Chronic
aspiration can lead to pulmonary morbidity and even permanent da-
mage of the lungs [8–10].
The physiologic process of swallowing includes oral preparatory,
oral, pharyngeal, and oesophageal phases. During these phases the
bolus is formed and transported into the stomach trough the or-
opharynx, hypopharynx and oesophagus [8,11–13]. It is a complex
process because swallowing and phonation all occur at the region of the
pharynx and larynx [3,14]. During pregnancy and mainly the first year
of life swallowing and feeding skills develop strongly, but the re-
lationship between the anatomical structures necessary for swallowing
keep on changing until adulthood. These maturational changes make
careful attention to timing of assessment essential [15,16]. By the age of
2–3 years, the larynx descends, thereby creating a shared passage in the
oral skills or reduced laryngeal function, problems of aspiration often
become evident at this age [6].
Evaluation of swallow and feeding problems starts with assessment
by a specialized speech and language therapist (SLT). The specific types
of assessments are defined by the setting, the age of the child, and the
child's presenting problems [9]. Different observational scales and
checklists can be used to systematically assess the state of the child,
readiness for feeding, oral-motor skills (non-nutritive and nutritive) and
swallowing safety [17–20]. During this assessment reasons for swal-
lowing problems can be identified.
There are different supplementary diagnostic tools to evaluate
feeding and swallowing problems. In children with a tracheostomy
tube, the modified Evans blue dye test (MEBDT) is a diagnostic test for
aspiration. With this method, methylene blue is mixed with the drink/
food and when methylene blue is sucked from the tracheostomy tube
after swallowing, the test is considered to be positive for aspiration
[21]. Video fluoroscopic swallow study (VFS) is useful for an objective
evaluation of the different phases of swallowing. With this imaging
technique all four phases of swallowing are assessed using pellets of
different consistencies, e.g. thin liquids, thick liquids, purees and solids.
Also, tethering of the larynx can be visualized with VFS [22–24]. VFS is
assumed to be relatively safe in terms of its radiation exposure risk

∗
Corresponding author. Department of Otorhinolaryngology, Erasmus Medical Center, Sophia Children's Hospital, Room SP 1455, Dr Molewaterplein 40, 3015 GD,
Rotterdam, the Netherlands.
E-mail address: l.veder@erasmusmc.nl (L.L. Veder).

https://doi.org/10.1016/j.ijporl.2019.05.003
Received 18 February 2019; Received in revised form 2 May 2019; Accepted 4 May 2019
Available online 16 May 2019
0165-5876/ © 2019 Elsevier B.V. All rights reserved.
M. Streppel, et al. International Journal of Pediatric Otorhinolaryngology 124 (2019) 30–33

[25]. Fiber-optic endoscopic evaluation of swallowing (FEES) is valu- Table 1

able in the evaluation of the pharyngeal phase of swallowing Demographics.
[18,20,26,27]. Complementary to VFS and FEES, the ‘Penetration-As- Total (n = 44)
piration scale’ can be used to systematically describe penetration and
aspiration events during swallowing, using a score ranging from 1 (no Male 27 (61.4)*
penetration or aspiration) to 8 (silent aspiration) [28].
Premature born 14 (31.8)*
Problems in one of the phases of swallowing can be caused by a
large range of anatomical and functional deficits in the oral cavity, Age at investigation 4.6 years (3 months–17
pharynx, larynx and oesophagus [12]. Swallowing problems in children years)**
with a tracheostomy tube might be due to the tracheostomy tube itself 0–1 years 8 (18.2)*
1–2.5 years 11 (25.0)*
or related to existing comorbidities. Reasons suggested in the tra-
2.5–5 years 11 (25.0)*
cheostomized adult population can also be applicable to the pediatric 5 years and older 14 (31.8)*
population. The tracheostomy tube might tether the larynx, cause de- Age placement tracheostomy tube 2.8 months (1 day–15
sensitization of the larynx, give loss of subglottic air pressure [29] and years)**
reduce the effectiveness of cough to clear secretions from the upper
Reason placement tracheostomy tube
airway [1,4,5,14,29–31]. The use of a speaking valve might thereby Laryngotracheal stenosis 15 (29.5)*
reduce penetration and aspiration, due to preservation of the subglottic Vocal cord paralysis/palsy 11 (25.0)*
air pressure and improvement of cough management [1–5]. Upper airway obstruction by craniofacial 6 (13.6)*
The aim of this study is to identify the prevalence and type of abnormalities
Tracheomalacia 5 (11.4)*
feeding and swallowing difficulties in children with a tracheostomy
Neurological disorders 3 (6.8)*
tube and to evaluate the used methods to diagnose these problems. Lymphangioma 2 (4.5)*
Tongue tumor 2 (4.5)*
2. Material and methods
Comorbidity
Neurological disorders 13 (31.8)*
We retrospectively collected data from our electronic patient system Craniofacial abnormalities 4 (9.1)*
of children with a tracheostomy tube between 2013 and 2016. Inclusion Neurological disorders and craniofacial 2 (4.5)*
criteria were children up to 18 years of age with an uncuffed tra- abnormalities
cheostomy tube and independent of mechanical ventilatory support at Additional (congenital) syndromes 2 (4.5)*

the time of investigation. All included children were used to eat or drink
at least one consistency at home.
Medical charts were reviewed for information on gender, age, age at
time of insertion of the tracheostomy tube, reason of insertion of the
tracheostomy tube, the presence of a speaking valve, medical history,
dependence on tube feeding.
All children were examined by one specialized SLT with 15 years of
experience in investigation and treatment in children with dysphagia.
The SLT observed the swallowing phases during eating and drinking of
the child with use of the “Neonatal Oral-Motor Assessment Scale”
[17,19], “the Early Feeding Skills Assessment” [18] and “the Ob-
servation List Spoon Feeding” [20]. The oral and pharyngeal phase
were assessed using as many consistencies of drinks or food as the child
was able/willing during the assessment. Observed features in the
swallowing phases are opening of the mouth, preparing liquids or food
for transport, transport of the bolus, swallow trigger, post-swallow
stasis and suspicion of laryngeal penetration and/or aspiration. A
stethoscope was used for laryngeal cervical auscultation to evaluate
indirect signs of inefficiency of the pharyngeal phase. MEBDT was
carried out in children as a screening tool for aspiration, knowing that
the swallowing function still can be inefficient even if no methylene
blue has been sucked out from the tracheostomy tube.
VFS was performed by a radiologist and an SLT. The oral and the
pharyngeal phase of swallowing were investigated with special atten-
tion for prespillage of food into the larynx/pharynx, tethering of the
larynx, residue in the pyriform sinus, epiglottis and/or valleculae, pe-
netration and/or aspiration. FEES was performed by a pediatric ENT-
specialist and an SLT, with attention for stasis of liquids or food in the
pyriform sinus, epiglottis and/or valleculae and for penetration and/or
aspiration. For both VFS and FEES, at least three swallows per con-
sistency were evaluated. Assessment by the SLT and additional in-
vestigation (MEBDT, FEES and/or VFS) always took place on the same
day. The Penetration-Aspiration scale [28] was used to interpret FEES
and VFS. All results of the additional investigation were analyzed.
3. Statistical analysis
Statistical analyses were performed using Statistical Package for
Speaking valve 9 (20.5)*
Dependent on tube feeding 30 (68.2)
*Data presented in numbers (%), ** Median age (range).
Social Sciences (SPSS) version 20.0 for Windows (2011, SPSS Inc.,
Chicago, IL, USA). Descriptive statistics were used. In addition, in-
dependent samples t-test were used to compare different kind of groups.
A p-value of < 0.05 was considered statistically significant.
4. Results
The study group consisted of 44 children with various comorbidities
and indications for tracheostomy. Data are shown in Table 1.
Clinical assessment by the SLT was performed in all 44 children,
additional investigations (MEBDT, FEES and/or VFS) in 36 (81.8%)
children. MEBDT was carried out in 36 (81.6%) children, of which 18
children aspirated. FEES was performed in six (13.6%) children, five of
these children showed aspiration, of which 4 without coughing. Five of
these children presented prespillage and three children displayed stasis
in the valleculae and sinus piriformis. VFS was done in nine (20.5%)
children. Six of these children showed silent aspiration. Five of them
presented prespillage, three children displayed prolonged stasis in
valleculae and sinus piriformis. In four children the tethering of the
larynx was insufficient. In one child with signs of pharyngeal problems
during investigation by the SLT, for unknown reasons, no further in-
vestigation was done. Only the children with swallowing problems re-
ceived therapy by a specialized speech and language therapist after-
wards.
The results of SLT, MEBDT, FEES and VFS were found to be com-
pletely consistent and additional investigation confirmed all clinical
observations made by the SLT.
Only 13 (29.5%) children did not show feeding and/or swallowing
problems. The oral and pharyngeal phase are equally difficult in chil-
dren with a tracheostomy tube. In addition, 15.9% of the children have
problems in both of these phases of swallowing (Table 2).
18 (94.7%) of the 19 patients with difficulties in the pharyngeal

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M. Streppel, et al. International Journal of Pediatric Otorhinolaryngology 124 (2019) 30–33

Table 2 Children with comorbidities showed more problems in the oral

Type of swallowing phase problems. phase. This might be due to the fact that the majority of the included
Total (n = 44) children suffered from craniofacial abnormalities and neurological
disorders which are associated with underdevelopment of the masti-
No problems 13 (29.5) catory muscles and limited active cheek and lip movements, which
Oral phase problems 12 (27.3)
features are likely to play a role in feeding difficulties [36]. Because
Pharyngeal phase problems 12 (27.3)
Oral and pharyngeal problems 7 (15.9)
problems in the oral phase of swallowing in our group mainly occur in
children with congenital abnormalities and children with neurological
Data presented in numbers (%). disorders, these problems don't seem to be caused by the tracheostomy
tube, but might be due to underlying problems.
Table 3 The mentioned mechanisms of impaired swallowing in the phar-
Type of performed swallow-investigation. yngeal phase for adult tracheostomized patients, with tethering and
Total (n = 44) (Signs of) aspiration
desensitization of the larynx, loss of subglottic air pressure and a less
(n = 19) effective cough, can also be applied to children with a tracheostomy
tube. In our study problems in the pharyngeal phase of swallowing
Only SLT investigation 8 (18.2) 1 (12.5) didn't arise in specific groups and during VFS and FEES many children
SLT investigation with MEBDT 24 (54.5) 10 (41.7)
presented sensitivity problems, little forceful swallowing and difficulty
SLT investigation, MEBDT and VFS 6 (13.6) 3 (50.0)
SLT investigation, MEBDT and FEES 3 (6.8) 2 (66.7) in tethering the larynx. These problems could at least partly be ex-
SLT investigation, MEBDT, FEES and 3 (6.8) 3 (100.0) plained due to the tracheostomy tube itself.
VFS In general, swallowing thick fluid is likely to be easier, therefore we
expected less swallowing problems in swallowing thick fluid [37]. But,
Data presented in numbers (%).
in this study, no difference was found between thin and thick fluid. This
might be caused by the tracheostomy tube that gives difficulties in te-
phase of swallowing aspirated, proven with additional investigations.
thering the larynx, which can lead to less protection of the airway, but
Half of them showed silent aspiration. Results of investigation by the
also to less powerful swallowing. The thicker the consistency, the more
SLT and additional examination (MEBDT, FEES and/or VFS) are shown
powerful swallowing has to be.
in Table 3.
Premature born children did not show more swallowing problems
Swallowing problems in various consistencies showed no significant
than term born children in our study. In the first months of life, we
differences, 18 (40.9%) children presented swallowing inefficiency
would have expected more swallowing problems due to problems in the
when drinking thin fluid, 14 of them also had difficulties in the phar-
coordination of sucking, swallowing and respiration [38]. It should be
yngeal phase of swallowing when drinking thick fluid or eating. 17
noted, that the average age at which the premature born children were
(39.2%) children were not able to eat solid food without problems in
examined was 3.5 years and it might be that if these children were
one of the swallowing phases.
investigated in the first months of their life, they might have shown
Children with problems in the oral phase of swallowing did not have
more swallowing related problems.
significantly more problems in the pharyngeal phase. After dividing the
Previously it has been shown in adult patients that patients without
children in four different age groups (0–1 year old, 1–2.5 years old, 2.5
a speaking valve aspirated more than patients who used a speaking
years old-5 years old and 5 years and older), no significant differences
valve [1–3,5]. This might be explained by the fact that a speaking valve
in efficiency of the phases of swallowing was seen.
is likely to preserve the subglottic air pressure, which is considered to
There was no difference in pharyngeal phase problems for all con-
be very important in the swallowing process. A speaking valve can
sistencies in children with or without speaking valve.
improve secretion management, bolus passage and cough management.
14 children had a congenital syndrome, including CHARGE, Cantú,
In children, these effects are less clearly defined [4,39–43]. In our study
VACTERL, Pierre Robin, di George, Pfeiffer, Stickler, Nager and
we couldn't find any effect of the speaking valve in the pharyngeal
Treacher Collins. These children and the remaining children with
phase but it should be noted that a relatively small group of 9 (20.5%)
neurological disorders had significant (p = 0.003) more problems in the
children accepted a speaking valve. Our clinical experience is that
oral phase of swallowing. All children with craniofacial abnormalities,
children, who accept a speaking valve, show less swallowing problems
including two children with Nager, one child with Treacher Collins and
using the speaking valve during swallowing.
one child with hemifacial microsomia, who were dependent on tube
FEES and/or VFS are considered to be the best tests for objective
feeding, had problems in the oral phase.
evaluation of the oropharyngeal phase of swallowing in patients
Premature born infants (n = 14) did not have significantly more
without a tracheostomy tube [18,26,27,44]. In our study aspiration
swallowing problems compared to term born children. Children who
could be confirmed in all children with suspicion of aspiration during
were independent on tube feeding didn't have feeding or swallowing
examination by the SLT. We found consistent results of SLT, MEBDT,
problems.
FEES and VFS which is probably due to the fact that all investigations
The period the tracheostomy tube was present at logopedic ex-
took place on the same day. The reliability of MEBDT however has been
amination ranged from 1 day to 15 years; children with a tracheostomy
questioned in literature; nevertheless it is suggested as a screening tool
tube placed in our hospital had logopedic examination as soon as
for determining aspiration [21,45].
possible, children referred from other hospitals depending later.
Although this is the first study that evaluates swallow and feeding
disorders in the pediatric tracheostomized population, we also ac-
5. Discussion knowledge the limitations. This retrospective study includes a small,
heterogeneous group of children with various comorbidities and in-
This study has shown that swallowing problems are very common in dications for tracheostomy. Therefore, it is difficult to draw definite
tracheostomized children, with 70% of the children having deficits in at conclusions about the exact causes of feeding and/or swallowing pro-
least one of the swallowing phases. Of these children 43% aspirated, of blems in relation to the tracheostomy tube. Nevertheless, we empha-
which half of them showed silent aspiration. It is important to be aware sized the importance of routine evaluation by a specialized SLT and
of this problem, because it can lead to respiratory problems, chronic therefore we recommend screening all children with a tracheostomy
lung disease [32–34] and feeding problems with an impaired nutri- tube for feeding and swallowing problems. Besides investigation by a
tional intake [35]. specialized SLT and using the MEBDT as a clinical tool, we recommend

32
M. Streppel, et al.
to perform a VFS and FEES, if possible, with and without speaking valve
with special attention to laryngeal tethering and sensitization problems
of the larynx.
Future research should focus on tracheostomized children with and
without underlying comorbidities to further explore the etiology of the
swallowing and speech problems and compare this with healthy chil-
dren and to take into account craniofacial anomalies and neurological
alterations.
6. Conclusion
Swallowing problems are very common in children with a tra-
cheostomy tube and there is a high risk for problems in the pharyngeal
phase of swallowing and risk for aspiration. Early logopedic examina-
tion should be part of the standard care in children with a tracheostomy
tube to diagnose and treat swallowing problems.
Compliance with ethical standards
There are no conflicts of interest in the materials or subject matter
dealt with in the manuscript.
All authors made substantial contributions to conception and de-
sign, acquisition of data, or analysis and interpretation of data. All
authors were involved in drafting the article or critically revising it for
important intellectual content. And, finally, all authors approved of the
version to be published.
The study was approved by the Clinical Research Ethics Committee
at our hospital.
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