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[Dysphagia] TBI / Epiglottic deflection (long post)



--- "Quinn, Darin" <QuinnD@rvh.on.ca> wrote:
there still exists some conflicting
> opinions as to whether the
> thyroepiglottic m. and aryepiglottic m. actively
> contribute to deflection.
There is no doubt left when one sees on AP view, the
epiglottis descending on one side but not the other
and there is evidence of inferior laryngeal nerve
involvement. The first part of the movement depends
entirely on the hyoid which pulls the epiglottis to
the horizontal. The rest is due to aryepiglottic and
thyroepiglottic function. Since the only thing a
muscle can do is contract, when these muscles cease
contraction, the epiglottis is "released" back to its
resting position.

including significant paralysis of the
> oral/facial musculature.
to increase
> range/strength/coordination
> of his oral/facial muscles as well as to decrease
> his pharyngeal delay and
> increase hyo-laryngeal excursion.
Since hyoid function is dependent on facial,
trigeminal, hypoglossal and parts of vagal input, how
much has his injury contributed to possible impairment
of this innervation? Since he can't formulate phonemes
I'm guessing that he has marked hypoglossal
impairment??
 
> Another important point is that he has a stoma that
> has healed open because
> of the extended period of time he was trached.
Have they checked for tracheal-skin fixation? When
this occurs, it can impede hyoid movement.

The
> scope showed good vocal fold adduction but a
> neurologically 'drooped'
> epiglottis which was partially blocking the airway. 
What do they mean by "neurologically drooped"? I can
guess but the definition is important re further
management. What I mean is, what neurological process
do they believe to be involved?

> I was able to schedule an MBS the next day to look
> at epiglottic movement
> during the swallow:  At rest, the epiglottis was
> drooped toward the PPW
> (approx. 60 degree angle) but deflected completely
> during the swallow (hyoid
> movement was moderately restricted, mostly the
> superior component, and CP
> opening was adequate). 
Many normals have no superior component because the
lack the smaller "incidental muscles" that contribute
to superior motion. It's the anterior movement that's
critical. If it deflected completely during the
swallow, then one can assume (also from the note re
vocal fold adduction) that the inferior laryngeal is
intact. What was arytenoid movement like?

 The problem was the return
> to rest position which
> was sluggish and, at times, did not happen until the
> next swallow (i.e., it
> became stuck in the deflected position). 
 This could only happen by continuous contraction of
the ary and thyro epiglottic. Perhaps that's what they
mean by "neurological drooping" - that would be my
guess anyway. THe AP view is important here. Does this
happen bilaterally?
 
> Questions:
I know that people can swallow safely without
> one but I assume that
> the rest of their swallowing mechanism needs to be
> in pretty good working
> order to do this
THe blade of the epiglottis is only cartilage and can
be removed with little or no effect on the swallow.
What MUST be retained is the base of the epiglottis
and the lateral arytenoids as these form the major
protection of the airway along with anterior movement
of the arytenoid masses.
> 
Is
> there a possibility for the epiglottis to 'right
> itself' at rest?
If the cause is continuous, or intermittently
continuous muscle contraction keeping it in the
deflected position, then not. I'm back at the
"neurologically drooping" point again. To me, that's
the critical issue - exactly what is meant by that?



=====
Dr I Campbell-Taylor
Clinical Neuroscientist
Suite 209, 134 Lawton Blvd
Toronto, ON, M4V 2A4
416-932-1443

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