954

DISTURBANCE OF SWALLOWING AFTER

TRACHEOSTOMY
S. A. FELDMAN C. W. DEAL
M.B., B.Sc. Lond., M.B. Sydney, F.R.C.S., F.R.C.S.E.
F.F.A.R.C.S. SENIOR REGISTRAR,
CONSULTANT ANÆSTHETIST CARDIOTHORACIC UNIT*

W. URQUHART
M.B. Edin., F.F.A. R.C.S.
SENIOR REGISTRAR, DEPARTMENT OF RADIOLOGY†
WESTMINSTER HOSPITAL, LONDON S.W.1
MOST patients with a tracheostomy can swallow food
and fluids normally, but sometimes, when a cuffed tracheo-
stomy tube has been inserted, they complain of difficulty
in swallowing (Robbie and Feldman 1963). We describe
here 3 patients who had a disordered swallowing-reflex
after tracheostomy. The disorder resulted in food and
fluid entering the larynx and producing tracheal soiling.
X-ray studies of the swallowing reflex showed that the dis-
order resembled in its effects the results of bulbar paralysis
although no neurological deficit was present. In all 3
patients the trachea was dilated: this may have been
caused by the accumulation of aspirated fluid and food
above the cuff of the tracheostomy tube producing
tracheomalacia and dilatation.
Case-reports
Case 1
This patient had had severe chronic bronchitis for many
years and the occasion in question his admission had been
on
precipitated by the development of bronchopneumonia. He
was admitted in respiratory failure which became worse in
spite of medical treatment and necessitated artificial ventilation
through an anterior tracheal-flap tracheostomy. He made
excellent progress initially but complained of difficulty in
swallowing fluids. Increasing volumes of air were required in
the cuff of his tracheostomy in order to obtain an air-tight seal
between the cuff and tracheal wall. A new tracheostomy tube
was inserted and 15 c.cm. of air were required to inflate the cuff
sufficiently to prevent a leak of air. In spite of this enormously
distended cuff, aspiration of the trachea showed the presence of
food in the tracheobronchial tree. It was thought that a tracheo-
oesophageal fistula had developed, and a barium swallow was
performed. The barium entered both the oesophagus and the
trachea, which was grossly distended (fig. 1). The cuffed tra-
cheostomy tube was replaced with an uncuffed silver tube and
the patient was fed through a nasogastric tube. The patient was
weaned off the ventilator with the assistance of a nikethamide
drip. Two weeks later a repeat barium swallow showed a per-
sistence of the swallowing disorder but this was now less
striking. The dilatation of the trachea was also diminishing.
* C. W. D. at
present holds a fellowship at the University of California.
&dag er; Present appointment: consultant, Newcastle General Hospital.
Fig. 2-A frame from a cinefilm of a gastrografin swallow. The disorder
of swallowing has produced massive tracheal aspiration.
Fig. 3-Drawing showing the main features of fig. 2: epiglottis (A); laryngeal
ventricle (B); and tracheostomy tube (C).
Fig. 1-A tracheogram produced by aspiration of barium during a
barium swallow, showing the grossly dilated trachea.
Case 2
A man with chronic bronchitis had a triple cardiac-valve
replacement with a Starr-Edward’s prosthesis. An anterior
tracheal-flap tracheostomy was performed and he was ventilated
artificially for ten days postoperatively. After this he became
reluctant to swallow and complained that " the food went down
the wrong way." Tracheal ballooning was evident, 20 c.cm. of
air were needed to inflate the cuff of a no. 11 James tracheos-
tomy tube to produce complete occlusion of the trachea. On
release of the cuff, food and saliva dammed above the cuff
entered his lower trachea necessitating a careful bronchial
toilet.
A silver tube with a speaking-flap was introduced and the
patient supported with intravenous therapy. Three days later
he had a cardiac arrest and died. At necropsy the trachea was
found to be grossly dilated with extensive mucosal erosion at the
level of the cuff and in the trachea above. His lungs showed
pneumonic changes consistent with repeated aspiration.
Case 3
This patient had a leaking abdominal aortic aneurysm re-
sected and grafted. He had had chronic bronchitis for many
years. Postoperatively, his respiration was inadequate and he
was artificially ventilated through a cuffed endotracheal tube.
The next day an anterior tracheal-flap tracheostomy was
performed and a James tracheostomy introduced. Recurrent
chest-infections made weaning from the respirator difficult.
After three weeks his spontaneous respiration was considered z
adequate and he was weaned trom the respirator. 1 he
James tracheostomy tube was replaced by a silver
tube.
Subsequently, he began to aspirate fluids and
developed bronchopneumonia. The silver tube was
replaced by a no. 12 James tube and the cuff inflated.
A cinefilm of ’Gastrografin’ swallow at this time
showed gross tracheal aspiration. Figs. 2 and 3 show
the ease with which the gastrografin entered the
larynx, the absence of normal laryngeal elevation,
and the absence of a glottic reflex. The trachea
became dilated as judged by the amount of air
needed to produce occlusion by the tracheostomy
cuff. This increased from 9 to 16 c.cm. Although
the patient was fed through a gastric tube, the aspira-
tion became progressively more serious, causing
pulmonary collapse and bronchopneumonia. Since
he could not tolerate being nursed while being held
down for more than five minutes, a simple larya-
 955

gectomy was performed as a life-saving procedure. Post- PROGRESSION OF RETROPERITONEAL

operatively did well and for three weeks had no further chest
he
FIBROSIS DESPITE CESSATION OF
infection and was able to eat normally. Unfortunately, three
weeks after the laryngectomy, when he was preparing for con- TREATMENT WITH METHYSERGIDE
valescence, he collapsed unexpectedly and died. FRANKLIN D. SCHWARTZ
Discussion M.D. Maryland
There seem to be three possible explanations of a dis- ASSISTANT PROFESSOR OF MEDICINE, UNIVERSITY OF ILLINOIS
COLLEGE OF MEDICINE, AND ASSISTANT ATTENDING PHYSICIAN,
order of swallowing produced by the tracheostomy:
PRESBYTERIAN-ST. LUKE’S HOSPITAL, CHICAGO
(1) Desensitation of the larynx resulting from the diversion
of the normal air current through the tracheostomy. GEORGE DUNEA
(2) Fixation of the larynx by the tracheostomy, especially M.B. Sydney, M.R.C.P., M.R.C.P.E.
with an anterior tracheal flap (Bjork 1960). This might prevent RESEARCH FELLOW, UNIVERSITY OF ILLINOIS COLLEGE
normal elevation of the larynx which is essential for coordinated OF MEDICINE AND PRESBYTERIAN-ST. LUKE’S
HOSPITAL, CHICAGO
swallowing.
(3) Compression of the oesophagus by the cuff in the trachea. METHYSERGIDE C’ Sansert’,Deseril’) an effective agent
The X-rays suggest that there is an incoordination of in the prophylactic treatment of migraine, seems to be
the swallowing-mechanism rather than a passive obstruc- causally related to the development of retroperitoneal
tion at the cuff level, which favours the first or second fibrosis (Lancet 1965, Graham 1966 et al.)-the process
explanations. All 3 patients had chronic bronchitis. regresses spontaneously after the drug is withdrawn and
Tracheal ballooning during coughing can be associated early surgical intervention is usually unnecessary. We
with the tracheomalacia that may develop in chronic describe here a patient in whom retroperitoneal fibrosis
bronchitis. The rapidity with which the trachea dilated continued to progress over a period of six months after
after the insertion of a cuffed tracheostomy tube and the the administration of methysergide was stopped.
inflammation of the mucosa above the tracheostomy seen Case-report
at necropsy in case 2 suggest that the tracheal ballooning A 59-year-old white man was admitted in November, 1964,
in these patients was secondary to the aspiration. Aspirated for evaluation of hypertension. He had been in good health
saliva and food probably accumulated above the tracheal
cuff, causing stagnation and infection which led to the
tracheomalacia. The weakened tracheal wall was then
distended by the tracheal cuff.
Conclusion and Summary
3 patients had a loss of the normal mechanism of swal-
lowing after an anterior tracheal-flap tracheostomy and the
use of a rubber, cuffed tracheostomy tube. This defect
may have resulted from a desensitisation of the larynx after
a diversion of the air-passage or a fixation of the larynx by
the tracheostomy. Tracheal ballooning with which it was
associated is considered to be secondary to the aspiration.
The 3 patients who had overt aspiration of food and fluid
as a complication were in a series of 328 patients in whom
this procedure had been undertaken. Many patients who
are reluctant to swallow after tracheostomy may, however,
be developing this condition, and an effort should then be
made to allow some air to be directed through the larynx.
Cuff inflation should be reduced to a minimum. Once the Fig. 1-Intravenous pyelogram showing a contracted right kidney;
mild calyectasis is seen on the left.
condition is fully developed it is very difficult to treat and
in spite of intravenous or gastric-tube feeding, saliva may
be aspirated. If all else fails, simple laryngectomy may be until six months previously when he had increasing weakness,
tiredness, and nocturia. Vomiting, dizziness, and swelling of
necessary to save the patient from the effects of repeated the legs and abdomen were first noted six weeks before
tracheal aspiration. admission. Hypertension was recorded for the first time two
We thank Mr. C. Drew and Mr. G. Westbury for permission to weeks before admission. He had gained 17 lb. (8 kg.) in weight.
describe cases 2 and 3. Fig. 1 first appeared in the British Journal of There was no decrease in urine output. Occasional lower back
Ancesthesia.
Requests for reprints should be addressed to Dr. S. A. Feldman, pain had been noted for about one year. He had had migraine
Department of Anaesthetics, Westminster Hospital, St. John’s for about thirty years and had been treated with methysergide,
Gardens, London S.W.I. 2-8 mg. per day for three years, but the drug had been dis-
REFERENCES continued several weeks earlier.
Bjork, V. O. (1960) J. thorac. cardiovasc. Surg. 39, 179. Physical examination revealed an alert elderly man. The
Robbie, D. S., Feldman, S. A. (1963) Br. J. Anœsth. 35, 771.
blood-pressure (B.P.) was 190/110 mm. Hg. The optic fundi
were normal. Slight cardiac enlargement, peripheral oedema,
"
The discussion concerning the use of the courtesy title doctor and a trace of ascites were noted. No epigastric bruit was heard.
for dental surgeons comes up periodically In view of the scope of
...
The haemoglobin was 12-5 g. per 100 ml.; blood-urea-nitrogen
dentistry today, for dentists to use the title might be just and it might (B.U.N.) was 172 mg. per 100 ml.; serum-creatinine 19-7 mg.
help to improve our standing with our patients, but without doubt per 100 ml.; serum-potassium 6-9 mEq. per litre; serum-
the general public forms its opinion of its dentists mainly according to
its experience when seeking and receiving treatment-the profession
bicarbonate 17-1 mEq. per litre.
has as many public relations officers as there are practitioners. Before After four days of bed-rest the B.P. had fallen to 140/80 mm.
deciding on this matter of title ourselves it might, perhaps, be a good Hg and spontaneous diuresis ensued. The B.U.N. fell to
idea to discover what our patients think about it."-British Dental 15 mg. per 100 ml. and serum-creatinine to 1-5 mg. per 100 ml.
Journal, April 19, 1966. A small right kidney with poor function and mild calyectasis