The Value of Speech Pathologists in the Treatment of Cardiac Patients
By Rene Jablonski, MA, CCC-SLP
Speech-Language Pathologist
The speech-language pathologist (SLP) receives a prescription for a swallowing evaluation on a patient who is status post-cardio-thoracic surgery or with an extensive cardiac history and although these consults might be infrequent, there are several reasons why a speech pathologist’s expertise in the areas of swallowing and voicing should be consulted in patient’s with cardiac history or surgery.
The Clinical Bedside evaluation is performed by the speech pathologist and allows for the SLP to gather information about a person’s swallowing ability for a variety of different liquid consistencies and diet textures. In addition, it is an evaluation that gives SLP’s a baseline on the person’s swallow and creates the foundation for the plan of care the patient may need from the speech-language pathologist.
So, now, I want to stop and take a minute to explain what exactly the clinical bedside evaluation was designed for.
1. The Purpose of the Clinical Bedside Evaluation
The clinical bedside evaluation is designed to provide the clinician with various data for use in dysphagia diagnosis and treatment planning. First, current medical diagnosis and in-depth feeding/swallowing medical history must be obtained. Second, the patient’s oral anatomy and labial and lingual control and manipulation of food are evaluated. Third, the assessment of the patient’s respiratory function and its relationship to the patient’s swallow function. Fourth, the patient’s palatal function and whether the patient is experiencing any nasal regurgitation is considered. Fifth, the SLP evaluated the patent’s pharyngeal contractility (squeeze strength), as it may affect pharyngeal clearance and movement of food through the pharynx ultimately leading to possible aspiration after the swallow. Sixth, the SLP assesses the patient’s laryngeal control, as airway protection may be reduced and aspiration during the swallow could occur. Seventh, the patient’s ability to follow directions and control their behaviors is taken into consideration and noted. And lastly, the patient’s reaction to oral sensory stimulation, including taste, temperature, and texture as well as the patient’s reactions and symptoms during their attempts to swallow is assessed.
Now that the purpose of the clinical bedside evaluation has been explained, we can go ahead and talk about the underlying reasons of why a speech-language pathologist should be consulted more when it comes to patients with cardiac history and/or are status post-cardiac surgery.
2. Vagus Nerve/Vocal cord Paralysis
The vagus nerve has a very long route, which goes through the neck into the chest and then wraps around some large blood vessels before it goes back up into the neck. Now keep in mind, there is a branch of the vagus nerve called the recurrent laryngeal nerve which controls the motion (opening and closing) of the vocal cords.
Now one might not know how close this branch comes to the heart, but its pathway is actually very close. It is adjacent to the large blood vessels near the heart and often can be affected or damaged during cardiac surgery. This can result in vocal cord dysfunction or paralysis.
You may be wondering, “So what if the vocal cords are damaged?” And, “What does that have to do with a person’s ability to swallow?”
But perhaps you do not know how important the vocal cords are in swallow function and airway protection
3. Vocal Cord involvement in the Swallow
A little known fact is that the vocal cords play a crucial role in airway protection during the swallow. If the vocal cords are not functioning to their full potential, the swallow protection they should be providing can be significantly altered.
It’s easier to understand if you picture the vocal cords like a shelf of tissue that adduct, or close, to effectively protect the airway and prevent food/liquids from entering the trachea. When food/liquid does enter the airway it is known as penetration (food/liquid enter the airway above the level of the vocal cords) and aspiration (food/liquid enter the airway below the level of the vocal cords).
Given this information, one might ask, “What happens when there is reduced movement of the vocal cords, or a vocal cord is paralyzed, or a vocal cord is swollen?” Reduced movement of a vocal cord can be the cause of aspiration during the swallowing because the larynx may be unable to protect the airway during the pharyngeal swallow. In addition, vocal cord dysfunction can affect a patient’s ability to sensate penetrated and aspirated material. An absent response to the penetrated or aspirated food in the airway is also known as silent penetration and silent aspiration. The end result of silent aspiration is that food/liquid that enters the trachea is not typically expelled due to an absent cough/sensation, putting the patient at a higher risk for aspiration pneumonia.
4. Vocal Cord paralysis after open-heart surgery
You now understand how vocal cords play a role in swallowing. The next concern is determining if the vocal cords were affected or not. Well, have you ever heard someone with a hoarse voice? Breathy voice? Or think to yourself, wow that voice sound raspy or harsh? Well, these vocal qualities are heard after cardiac surgery or in a patient with an extensive cardiac history. And if heard, this is a red flag.
A patient status post-cardiac surgery has a greater chance of a left-sided vocal cord injury due to the recurrent laryngeal nerve’s long intra-thoracic segment (Hamdan et al, 2002).
Patients who do have unilateral vocal cord paralysis usually present with dysphonia, or a hoarse, breathy or rough voice, with sudden breaks or fading of the voice. The patient can also have a strained or tight vocal quality and experience tightness and muscle aches in the throat.
It is important to remember that this change in vocal quality is often overlooked as an insufficient cough, respiratory insufficiency, or stridor from status post endotracheal intubation. But what is not often understood is that these symptoms can lead to major complications such as aspiration pneumonia and recurrent pneumonia. These conditions ultimately result in prolonged hospitalizations, recurrent hospitalizations for aspiration pneumonia, decompensation, and require reintubation and mechanical ventilation.
5. What is Dysphagia Aortica and how does it affect the swallow?
As speech-language pathologists, it is our job to assess the swallow and often we will get a patient complaining of food getting stuck and/or a globus sensation. We will often do an objective swallow study to find out why the person is experiencing those feelings and sometimes the reason is unclear.
Have you ever heard of Dysphagia Aortica?
Dysphagia Aortica is a rare cardiac condition of a patient with extensive cardiac histories is Dysphagia Aortica which is external compression of the distal esophagus from an enlarged, dilated or aneurysmal thoracic aorta leading to mechanical obstruction of the food bolus. This is a rare condition that can cause dysphagia, but is nevertheless on that must be considered.
A case study was performed by Mouawad and Ahluwalia, on an 82-year old Caucasian male with significant cardiovascular history. The subject was experiencing chronic episodes of dysphagia to solids that had progressively worsened to liquids. During the patient’s medical work-up, he underwent several diagnostic procedures. It was noted within the case study that a patient with Dysphagia Aortica generally presents with progressively worsening dysphagia (initially solids to liquids), along with constitutional symptoms of nausea, anorexia, unintentional weight loss, and malnutrition.
6. Conclusion
Dysphagia is a serious medical condition that represents an urgent threat to patient safety. When considering patients with a history of cardiac surgery or cardiac disease, the skilled Speech Language Pathologist must remain aware of some of the insidious causes of dysphagia.
Speech-Language Pathologists should be suspicious and consider the possibility of vocal cord involvement during their Clinical Bedside Evaluations. Speech-Language Pathologists must consider, that as a result of neck or chest surgeries, vocal cord paralysis secondary to cranial nerve involvement (damage) can present with symptoms of dysphonia along with respiratory and airway clearance complications. The symptomology associated with Dysphagia Aortica represents a diagnostic and management challenge for all members of the multi-disciplinary team, but one that the SLP can assist with identifying early if awareness is high.