Question
I have a patient who recently underwent a carotid endarectomy and has developed swallowing problems. He also is recovering s/p CABG (Coronary Artery Bypass Graft Surgery). Today, I asked the physician if he felt the swallowing problems were a result of ed
Answer
Regarding the CABG and subsequent dysphagia, Hogue et al. (1995) reported that patient age, time of an intra-aortic balloon pump, duration of intubation, and intra-operative implementation of TEE were all important independent predictors for silent aspiration. I would try and determine how any of these variables may have impacted the patient. The left branch of the recurrent laryngeal nerve has a lengthy path. Therefore, it is possible for potential surgical associated injury at several different locations. The nerve descends the aorta immediately after leaving the vagus nerve. At this point the RLN can be impacted by manipulation during surgery or by cold temperature during external cooling of the heart (Tewari et al., 1996). Impairments to the RLN may potentially impact processes in the swallow including glottic closure, resulting in dysphagia and subsequent aspiration risk.
Regarding carotid endarterectomy (CEA), there may be several reasons for impact to the pharyngeal phase of the swallow. During the procedure, it is known that some surgeons place a shunt, which is a plastic tube. This is done to preserve blood flow (Sandman et al 1993). It is possible to have negative results of shunt placement. Some of these may include hematoma at the insertion site in the neck and nerve injury. You may wish to find out if this method was used in your patient's procedure.
Other issues sometimes associated with CEA in addition to cranial nerve impairment can include bleeding and airway swelling even without shunt use. Based on the anatomical landmarks present during this surgery, it is possible to have hypoglossal nerve dysfunction and vagus nerve dysfunction to the superior laryngeal nerve and recurrent laryngeal nerve (RLN) branches. These particular injuries are often attributed to surgical traction (Ballotta et al 1999). The RLN functions are discussed in the prior paragraph. The internal branch of the superior laryngeal nerve is the sensory nerve in the supra-glottis and is the nerve assessed during FEESST exams. Although the CABG and CEA are performed in two different anatomical regions, each has close proximity to nerve functions which are crucial to pharyngeal swallow function.
Ballotta E. et al (1999). Cranial and cervical nerve injuries after carotid endarterectomy: a prospective study. Surgery, 125:85-91.
Sandmann W. et al (1993). Risks and benefits of shunting in carotid endarterectomy. Stroke 24:1098-9.
Hogue, C.V. et al. (1995). Swallowing dysfunction after cardiac operations: associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography. Journal of Thoracic Cardiovascular Surgery, 110, 517-522.
Tewari, P. et al. (1996). Combined left-sided recurrent laryngeal and phrenic nerve palsy after coronary artery operation. Annals of Thoracic Sugery, 61, 1721-1723.
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Eric Blicker, M.A., CCC-SLP.D, BRS-S, is an ASHA board recognized specialist in swallowing disorders. Eric received his doctoral degree from Nova Southeastern University and was trained in FEESST by Dr Jonathan Aviv, the otolaryngologist who developed FEESST. He has provided FEES training courses in CT, MA, FL, MO, CA.
