INTRODUCTIONSwallowing is one of the most complexes neuromuscular processes of the human body. It has a voluntary and an involuntary component, the latter involves more than a dozen muscles and lasts only few seconds (Marchesan, 1999).
Semi-solid foods need lower skills of the swallowing movements of the larynx and pharynx to be swallowed than liquid foods (Dantas et al., 1990). A relevant fact, since postoperative diet in tonsillectomy involves basically foods with this kind of texture.
There are several ways to study the history of swallowing: patients history and physical examination to evaluate changes in the oral phase (Marchesan, 1999); ultra-sound, used to study the movements of the tongue during the oral phase; videofluoroscopy that is used to study preparatory oral phase, pharyngeal and esophageal phases of swallowing, in which an opaque radiation contrast is used; and most recently swallowing video endoscopy was introduced and it studies the pharyngeal phase of swallowing and provides data that may suggest changes in the preparatory oral phase (Macedo, 1998).
The evaluation of swallowing after tonsillectomy is poorly known, and no studies were found concerning this issue. However, this type of swallowing video endoscopy evaluation was reported as safe for both adults (De Paula, 2000, Aviv, 2000, Macedo, 1998, Dua, 1997, Costa, 1996) and children (De Paula, 2002, Leder, 2000), and it enabled us to check whether there was any change in the examination after tonsillectomy.
Odynophagia was an extremely important complaint after tonsillectomy, and was the primary one of those patients in the early postoperative period. Therefore, the authors decided to study dysphagia in such patients to clarify the likely causes of changes in swallowing after tonsillectomy.
OBJECTIVESTo evaluate pharyngeal phase of swallowing in young adult patients in the postoperative period of tonsillectomy, and to observe if there were abnormalities and what they were.
MATERIAL AND METHODSSixteen volunteer patients (07 men and 09 women) from 17 to 24 years old, mean age of 20 years old, have undergone tonsillectomy followed by swallowing video endoscopy between the 7th and 10th day postoperative.
All patients were operated on according to the same surgical technique: Rose position, infusion of the anterior pillars with 1 ml of 2% xylocaine solution with vasoconstrictor at 1:200,00, in the lower, middle and upper portions, dissection with tonsils detaching aspirator, homeostasis with plain catgut 3-0 stitches.
Patients were discharged in the first postoperative day with the same medical prescription to be used at home in current dosage of oral 500 mg Amoxicillin every 8 hours for seven days, 50 mg of sodium dichlofenac every 8 hours for 05 days, and 35 drops of Sodium Dipyrone every 6 hours, as required. Patients were directed to return on the 7th day after surgery and patients did not report any feeding problems, in spite of referring to odynophagia at several degrees.
Between the seventh and tenth postoperative day patients have undergone swallowing video endoscopy and the technique was as follows: patient was seated with supported feet, and monitor in front of them to provide a "biofeedback" and to increase patient's cooperation during the procedure. Local anesthetic drug was not used in the nose or in the pharynx. The food offered was a thick white liquid food (plain yogurt) in a plastic container and it was sucked through a plastic straw. Next, endoscope was positioned in the paranasal sinuses in order to visualize soft palate functioning during swallowing and/or if there was nasal reflux. After that, the endoscope was placed at the level of the uvula in order to capture a good view of the base of the tongue, lateral and posterior pharyngeal walls, larynx vestibule, pyriform sinuses, valleculae and the closing pattern of the airways during swallowing. The patients were also requested to keep yogurt in the mouth to find out if there was any posterior leakage.
All exams were taped in videocassette, to be reevaluated whenever necessary.
First, the patient was requested to swallow without the yogurt to observe muscle activity and saliva clearance in pharyngeal recesses. Second, we asked the patients to swallow the yogurt at a normal pace, whenever necessary until they feel a clearness sensation. Third, we repositioned the tip of the device in the nasal cavity to see if there was any yogurt residue in it (nasal reflux).
Finally, we analyzed the behavior of the yogurt during swallowing, checking some parameters such as: posterior leakage, the way food traveled, pharyngeal clearance after swallowing, number of swallowing movements to achieve clearness sensation, penetration, aspiration and occasional nasal reflux.
Video files from a former study carried out in the same service were used as the control group (De Paula - 2000). These videos recorded pharyngeal phase behavior during swallowing in normal individuals within approximately the same age range, with the same sequence of maneuvers formerly described for the application in patients after tonsillectomy.
The method determined:
- Penetration: food flow through the larynx, without however trespassing vocal folds; and,
- Aspiration: foods flow through the larynx trespassing vocal folds.
RESULTSAll patients reported the feeling of pharyngeal clearness after swallowing without yogurt.
All patients had normal vocal folds and were able to keep the yogurt inside the mouth before starting to swallow. Moreover, food aspiration did not occur in any patients.
While the yogurt was swallowed, the following sites seemed dyed in all patients namely, the valleculae, posterior wall of the pharynx and pyriform sinuses.
All patients had proper functioning of the palate velum during swallowing, with total closure of the paranasal sinuses, without events of food reflux to the nasopharynx.
Two patients (12.5%) had penetration of food in the larynx and it was satisfactorily cleaned after one coughing movement.
The average of swallows required to completely clean all pharyngeal recesses was 4.8. One patient (6.25%) required only two swallows to clean the larynx, 11 patients required (68.75%) 3 to 5 swallows and 4 (25%) required more than 5 swallows to clean the larynx, and the maximum number of swallows was 7 (Graph 1).
Ten patients (66.6%) reported the sensation of clean larynx after swallowing, however, they still had yogurt present in the pyriform sinuses.
In the normal group (control group), we observed a need for a maximum of 2 swallows to achieve clearness sensation, and all patients did not have yogurt penetration, aspiration or build up in the pyriform sinuses.
In spite of the required swallowing, none of the patients had posterior leakage or food aspiration.
GRAPH 1
The pharyngeal phase is essential for swallowing dynamics, since it involves a common path between the respiratory and digestive systems, and any issues in this phase will increase the risk of aspiration and morbidity of patients with such abnormalities.
The study showed that there are changes in the swallowing patterns of normal patients that have undergone tonsillectomy. This fact draws the attention to potentially severe swallowing disorders in formerly dysphagic patients, e.g. those individuals with congenital or acquired neurological disorders who are indicated for tonsillectomy. In such cases, the consideration for surgery should take into account the likelihood of having food aspiration immediately after the surgery. Decreased clearance is likely to increase the risk of penetration and/or food aspiration, due to the existing abnormalities of such pathological patients.
Many studies were concerned about postoperative pain (Salonen, 2001, Palme, 2000), infections (Kaygusuz, 2001) or hemorrhage (Krishna, 2001, Bhattacharyya, 2001) after tonsillectomy; however, we did not find any studies that investigated dysphagia during patients' recovery. Such dysphagia may be very important for previously dysphagic patients.
This study was concerned with the involvement of the swallowing pharyngeal phase in patients that have undergone tonsillectomy, in which an increased need for swallowing movements was clearly observed.
We were amazed to find out that even when the patient reported complete clearness sensation, there were still residues present in the pyriform sinuses in 66.6 % of the cases and this fact, associated with the observation of two pharyngeal penetrations (12.5%), made us think in a likely decrease of pharyngeal sensibility, possibly as a result of the local edema caused by the surgery, in addition to the difficulty in elevating the pharynx during swallowing, and the decrease in the piston-like force of the base of the tongue caused by postoperative pain.
All in all, penetration occurred in two cases and lower airways protection was fully kept, and the two patients promptly expelled the residues.
Future studies, however, should address potential risks of tonsillectomy particularly in patients with neurological diseases and existing abnormal swallowing pattern.
CONCLUSIONWe concluded that in the postoperative recovery of tonsillectomy dysfunctions occur in the swallowing pharyngeal phase, and the most important ones were:
- Increase in number of swallows required to provide the clearness sensation of the pharynx, or in other words, decreased "clearance".
- Presence of food in pyriform sinuses reported in most of the patients (66.6%) while they reported clearness sensation of pharynx and larynx.
- There was no posterior leakage of food.
- There was no nasal reflux.
- There was no aspiration.
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1 - Resident Physician, Department of Otorhinolaryngology, Santa Casa and Hospital Irmãos Penteado de Campinas.
2 - Joint Physician, Department of Otorhinolaryngology, Santa Casa and Hospital Irmãos Penteado de Campinas.
3 - Physicians, Preceptor professors, Department of Otorhinolaryngology, Santa Casa and Hospital Irmãos Penteado de Campinas.
Address correspondence to: Rua Barreto Leme, 1550. Centro - Campinas CEP: 13010-201
Tel-fax: (55 19) 3232-4478 e-mail: gilbertolpsn@uol.com.br
