Dec. 3, 2012 Johns Hopkins experts are recommending early post-surgical assessment -- preferably within 24 hours -- for trouble chewing and swallowing food, or speaking normally, among patients who have had benign tumors removed from the base of the brain.
Such early assessments, they say, may minimize complications associated with the sometimes hazelnut-sized tumors, called vestibular schwannomas. Damage can arise when the tumors themselves press 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 a trio of surveys the team conducted, the latest of which is to be published in the December edition of the journal The Laryngoscope, showing such complications after brain-tumor surgery were several times more common than previously thought.
They also found that post-surgical dysphagia and vocal cord paralysis were associated with other illnesses, including pneumonia, especially if 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 complications with swallowing and vocal cord paralysis can exact on health and recovery, even though such problems are not well-reported," says laryngologist and study senior co-investigator Lee Akst, M.D. Each year, Akst says, his team treats more than a dozen patients who have voice problems after surgery to remove mostly benign vestibular schwannomas, for which the number of new cases reported annually in the United States is estimated at less than 10,000.
"Physicians and speech therapists really need to closely monitor their patients for early signs and symptoms, such as breathy, whispery voices and trouble keeping food in their mouth while chewing, so that aggressive therapy with exercise, medications or further surgery can be quickly considered," says Akst, an assistant professor at the Johns Hopkins University School of Medicine and director of its Voice Center.
The Johns Hopkins team's latest study findings were based on a review of the hospital records of 17,261 men and women participating in the National Inpatient Survey (NIS). Researchers discovered that swallowing problems, or dysphagia, were reported in 443 patients (or 2.6 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 in the time patients needed to recuperate in the hospital: When there were no complications, the average hospital stay was 5.3 days; when dysphagia occurred, the average stay was 11.7 days, and when there was vocal cord paralysis, the average stay was 12.1 days.
Moreover, researchers found, patients who developed swallowing problems were almost twice as likely to be sicker than patients whose swallowing remained normal. Also, dysphagic patients were nearly 18 times more likely to aspirate food into their lungs than non-dysphagic patients (at 7.1 percent and 0.4 percent, respectively), and six times more likely to need immediate, follow-up care and admission to another rehabilitation or chronic care facility (at 48.5 percent versus 7.7 percent). One in five needed a feeding or gastrostomy tube installed, researchers say.
In addition, patients experiencing vocal cord paralysis were four times more likely to be discharged to another health care facility instead of going home (at 32.7 percent versus 7.7 percent). One in eight needed a breathing or tracheostomy tube placed in their throat to enable speech.
Researchers estimated the increased cost of care for such post-surgical problems ranged between $35,000 and $50,000 per patient, 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 the year in the journal Otolaryngology-Head and Neck Surgery, had shown much higher post-surgical complication rates. In studies of 181 patients who had vestibular schwannoma surgery at The Johns Hopkins Hospital between 2008 and 2010, 57 (31 percent) developed swallowing problems and 19 (10 percent) had difficulty speaking.
According to Christine Gourin, M.D., M.P.H., senior co-investigator on the Laryngoscope study and an associate professor at Johns Hopkins, the NIS and Hopkins-specific study numbers are "likely an underestimate of the real problem" because historically, physicians, residents and nurses have not looked for specific post-surgical problems at the outset.
Gourin, director of the Clinical Research Program in Head and Neck Cancer at Johns Hopkins' Kimmel Cancer Center, says rehabilitative therapies, including drug therapies and surgery are available to patients who do develop complications, but these remedies produce their best results when administered early.
Dysphagic patients, Akst says, can often adapt to prevent spillage by drinking with a straw or from a bottle instead of a cup. They can also learn to prevent food from falling out while eating, by tilting their head back slightly or by chewing only on one side. Tongue- and jaw-strengthening exercises can also help recovery. More complicated cases could require injections of calcium beads or other so-called "fillers" into the vocal cords or soft palate to prevent food from going down the "wrong way" or into the nose.
Similar injections in the lip and even surgical implants can also be used to treat damaged lips, says Akst, helping patients to pronounce sharp "b" and "p" sounds and making it easier to force air out of the lungs 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 and pre-existing medical conditions might put patients at greater risk of post-surgical complications. Volunteers for the study will likely have neurofibromatosis, a genetic nerve condition that often results in vestibular schwannomas. Researchers hope that by monitoring patients before they have surgery, the scientific team can gain a better understanding of who does and does not develop dysphagia and vocal cord paralysis. The team also has plans to evaluate which medical and rehabilitative therapies work best at resolving the problems.
Funding support for this study was provided by The Johns Hopkins Hospital.
In addition to Akst and Gourin, other Johns Hopkins researchers involved in these analyses were Bryan Ward, M.D.; Howard Francis, M.D.; Simon Best, M.D.; Heather Starmer, M.A.; Yuri Agrawal, M.D.; Alexander Hillel, M.D.; Wade Chien, M.D.; and Rafael Tamargo, M.D.
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- Bryan K. Ward, Howard W. Francis, Simon R. Best, Heather M. Starmer, Lee M. Akst, Christine G. Gourin. National prevalence and impact of perioperative vagus nerve injury in vestibular schwannoma. The Laryngoscope, 2012; DOI: 10.1002/lary.23605
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