Johns Hopkins experts are recommending early post-surgical assessment-- preferably within 24 hours -- for trouble chewing and swallowingfood, or speaking normally, among patients who have had benign tumorsremoved from the base of the brain.
Such early assessments, they say, may minimize complicationsassociated with the sometimes hazelnut-sized tumors, calledvestibular schwannomas. Damage can arise when the tumors themselvespress on the nearby cranial nerves -- key to controlling the tongue,lips, mouth and throat -- or from the surgery itself.
Researchers say their recommendation is based on study results from atrio of surveys the team conducted, the latest of which is to bepublished in the December edition of the journal The Laryngoscope,showing such complications after brain-tumor surgery were severaltimes more common than previously thought.
They also found that post-surgical dysphagia and vocal cord paralysiswere associated with other illnesses, including pneumonia, especiallyif they necessitated implantation of feeding or breathing tubes.These complications, in turn, led to longer, costlier hospital stays,or additional care at rehabilitation facilities.
"Our results show the tremendous toll post-surgical complicationswith swallowing and vocal cord paralysis can exact on health andrecovery, even though such problems are not well-reported," sayslaryngologist and study senior co-investigator Lee Akst, M.D. Eachyear, Akst says, his team treats more than a dozen patients who havevoice problems after surgery to remove mostly benign vestibularschwannomas, for which the number of new cases reported annually inthe United States is estimated at less than 10,000.
"Physicians and speech therapists really need to closely monitortheir patients for early signs and symptoms, such as breathy,whispery voices and trouble keeping food in their mouth whilechewing, so that aggressive therapy with exercise, medications orfurther surgery can be quickly considered," says Akst, an assistantprofessor at the Johns Hopkins University School of Medicine anddirector of its Voice Center.
The Johns Hopkins team's latest study findings were based on a reviewof the hospital records of 17,261 men and women participating in theNational Inpatient Survey (NIS). Researchers discovered thatswallowing problems, or dysphagia, were reported in 443 patients (or2.6 percent) who had had a vestibular schwannoma removed. Some 117(0.7 percent) patients suffered some form of vocal paralysis.Developing either problem was associated with a more than doubling inthe time patients needed to recuperate in the hospital: When therewere no complications, the average hospital stay was 5.3 days; whendysphagia occurred, the average stay was 11.7 days, and when therewas vocal cord paralysis, the average stay was 12.1 days.
Moreover, researchers found, patients who developed swallowingproblems were almost twice as likely to be sicker than patients whoseswallowing remained normal. Also, dysphagic patients were nearly 18times more likely to aspirate food into their lungs thannon-dysphagic patients (at 7.1 percent and 0.4 percent,respectively), and six times more likely to need immediate, follow-upcare and admission to another rehabilitation or chronic care facility(at 48.5 percent versus 7.7 percent). One in five needed a feeding orgastrostomy tube installed, researchers say.
In addition, patients experiencing vocal cord paralysis were fourtimes more likely to be discharged to another health care facilityinstead of going home (at 32.7 percent versus 7.7 percent). One ineight needed a breathing or tracheostomy tube placed in their throatto enable speech.
Researchers estimated the increased cost of care for suchpost-surgical problems ranged between $35,000 and $50,000 perpatient, and extended the time needed in the hospital by an average 1.7 days.
Two previous studies by Akst and his team, published earlier in theyear in the journal Otolaryngology-Head and Neck Surgery, had shownmuch higher post-surgical complication rates. In studies of 181patients who had vestibular schwannoma surgery at The Johns HopkinsHospital between 2008 and 2010, 57 (31 percent) developed swallowingproblems and 19 (10 percent) had difficulty speaking.
According to Christine Gourin, M.D., M.P.H., senior co-investigatoron the Laryngoscope study and an associate professor at JohnsHopkins, the NIS and Hopkins-specific study numbers are "likely anunderestimate of the real problem" because historically, physicians,residents and nurses have not looked for specific post-surgicalproblems at the outset.
Gourin, director of the Clinical Research Program in Head and NeckCancer at Johns Hopkins' Kimmel Cancer Center, says rehabilitativetherapies, including drug therapies and surgery are available topatients who do develop complications, but these remedies producetheir best results when administered early.
Dysphagic patients, Akst says, can often adapt to prevent spillage bydrinking with a straw or from a bottle instead of a cup. They canalso learn to prevent food from falling out while eating, by tiltingtheir head back slightly or by chewing only on one side. Tongue- andjaw-strengthening exercises can also help recovery. More complicatedcases could require injections of calcium beads or other so-called"fillers" into the vocal cords or soft palate to prevent food fromgoing down the "wrong way" or into the nose.
Similar injections in the lip and even surgical implants can also beused to treat damaged lips, says Akst, helping patients to pronouncesharp "b" and "p" sounds and making it easier to force air out of thelungs to project sound. The most common rehabilitation exercises,however, are basic voice lessons to strengthen the cords.
Researchers say the team next plans to study what social andpre-existing medical conditions might put patients at greater risk ofpost-surgical complications. Volunteers for the study will likelyhave neurofibromatosis, a genetic nerve condition that often resultsin vestibular schwannomas. Researchers hope that by monitoringpatients before they have surgery, the scientific team can gain abetter understanding of who does and does not develop dysphagia andvocal cord paralysis. The team also has plans to evaluate whichmedical and rehabilitative therapies work best at resolving the problems.
Source: Johns Hopkins Medicine