Dysphagia and Traumatic Brain Injury
Authors: Alexa Sennyey, Andreza Maciel dos Santos, Cibele Ricardi;
Country: São Paulo, Brazil.
Dysphagia is the term used to describe any deficit on the deglutition that can occur, from the lips to the stomach. The Speech Language Pathologist (SLP) is the professional who studies the organs and the function of the oral cavity, pharynx and larynx (Perlman, 1994). Dysphagia is not an illness, but the symptom of one or more pathologies (Kuhlemeier, 1994). It can be caused by neurological deficits, cancer, AIDS, etc. In this paper we will discuss dysphagia on the Traumatic Brain Injured (TBI) patient.
Because of the difuse nature of the lesion on a TB Injured patient, the risks of damaging structures responsible for the deglutition, e.g. cranial nerves (V, VII, IX, X e XII), central nervous system, are greater. Another common reason for deglutition disturbances in TBI patients is the secondary complications, e.g. anoxia, intra-cranial pressure, hyperthermia, seizures, etc. After a longer period of coma, abnormal muscular tone can be found (Cherney, 1994); from the entubation, lesions on the vocal-cords function can be found and the interaction of cognitive, behavioral and linguistic disturbances, with the dysphagia all this must be considered (Ylvisaker and Logeman, 1986). Comparison will be done between with what was found in the literature and in the Hospital Arthur Ribeiro de Saboya, in São Paulo, Brazil regarding dysphagia and traumatic brain injured patients. This research is looking for the type of lesion, TBI or head injury (HI) as a result of gun shot and clinical evaluation of the deglutition function.
In the group of TBI patients, 13% presented dysphagia, 7.8% of the dysphagia population had dysarthria and 7.8% had some cognitive disorder. The group of HI from gun shot, 37.5% had dysphagia, 12.5% of the dysphagia population had dysarthria, and 37.5% had some cognitive disorder.
Robbins (1993) found that left hemisphere lesion increased time of the laryngeal phase, that he related to as an oral incoordination.. Right hemisphere lesion caused longer time to initiate the deglutition as well as the pharyngeal reflex to occur. Aspiration and penetration was higher in this group. The population with anterior lesion had a longer time on the pharyngeal phase than the group with a posterior lesion.
TBI patients commonly have frontal lobe lesion, consequently have difficulties on planning, impulsivity and attention deficit (Hutchins, 1989; Mackey and Morgan, 1993). These disturbances worsen deglutition performance and only with cognitive rehabilitation can they improve.
Dysarthria is another frequent disturbance on TBI cases, mainly on CHI and diffuse injuries. Dysarthria can bring severe consequences to the performance on deglutition, regarding the oral phase. Incoordination is a common symptom that deteriorate performance of the lips and tongue, causing possible penetration of food and if the vocal-cords movement of abduction, and adduction is compromised, it highers the risk of aspiration, and consequently the risk of pneumonia. Oral dyspraxia can also cause an incoordination of the movement on the oral phase, causing penetration or even aspiration of the bolus (Jones and Donner, 1990).
Signs that can indicate risk of aspiration are (Perlman, 19 97):
Bedside, clinical evaluation is the first step to detect a deficit on the patients ability to swallow without risk. More sensitive evaluation include: videofluoroscopy, fiberoptic endoscopy, ultrasound, manometry, eletromiography and cervical auscultation. It is the SLPs role to decide which of the procedures will be more efficient and which will give more information about the muscles and their function, for each particular case. The bedside evaluation will include: posture, time of bolus formation in the oral cavity, time of initiation of the swallowing reflex, pattern of oral muscles movement, presence of coughing, residue in the oral cavity, nasal reflux, level of cognition of the patient (Logemann, 1985; Perlman, 1997). At the Hospital Arthur Ribeiro de Saboya, São Paulo, Brazil, the bedside evaluation and cervical auscultation are used to define presence of dysphagia.
The preliminary results of this work shows the risk that these patients with a traumatic brain injury or head injury from gun shot have acquired pneumonia from aspiration. It shows that on the first 30 days post injury the risks of aspiration are greater, and therefore a careful evaluation of the deglutition abilities of these patients is needed and depending on the results, intervention of a Speech-Language Pathologist is required to decide with the professionals involved, which way of feeding and which consistency as per mouth feeding is the best for the patient.
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