Comprehensive Rehabilitation for Epiglottis Dysfunction Due to Cut

Injury of Neck with Respiratory and Swallowing Problems

Dian Marta Sari

, Arnengsih Nazir

, Marina A. Moeliono

, Tri Damiati Pandji

Department of Physical Medicine and Rehabilitation, Dr. Hasan Sadikin General Hospital, Faculty of Medicine University

of Padjadjaran,, Bandung, Indonesia

Keywords: Comprehensive Rehabilitation, Epiglottis Dysfunction, Respiratory Problem, Swallowing Problem

Abstract: An interesting case was referred to the Physical Medicine and Rehabilitation (PMR) department with

neglected ‘vulnus scissum at the left side of the neck with exposed larynx and partially cut epiglottis’.

Assessment of the patient showed epiglottis dysfunction, which caused the problem of swallowing,

persistent coughing with lots of sputum, and the risk of aspiration. This was resulted in malnutrition, and

prolonged hospitalization lead to deconditioning. Rehabilitation program was initiated cautiously, begun

with improving the general condition, nutritional status and airway protection. Rhino-Laryngo Fiberscope

(RLF) was done several times to assess the function of the epiglottis. Pulmonary rehabilitation consisted of

exercise for effective coughing, airway clearance, chest wall mobilization or chest expansion and trunk

flexibility. Posture training was added to achieve proper position needed for feeding. Rehabilitation of the

deconditioning syndrome is also essential for functional recovery. Seven weeks of rehabilitation resulted in

improvement of the general condition, including nutritional status. RLF showed a functional epiglottis,

which ensured normal swallowing. This case and all its effects, required a comprehensive rehabilitation

program, implemented step by step to manage all problems. At the end, the goal of medical rehabilitation in

improving quality of life in this patient was achieved.

1 INTRODUCTION

Patient with injury to the anterior part of the neck

bears a high risk of morbidity associated with the

aerodigestive tract and vascular structure in that area

(Panchappa, 2014). Due to its position which is

close to the surface and therefore unprotected, the

larynx is one of the most vulnerable organ in the

neck area, aAnd as such is commonly injured in

trauma to the neck, especially penetrating injuries.

Since the larynx is a structure with essential function

in both respiratory and digestive systems, it is

related to high morbidity and prolonged

hospitalization. Therefore, after life saving

management of the emergency condition, a

comprehensive rehabilitation program should be

implemented for patients with injury to the larynx.

After surgical repair, carefull evaluation of all

functions of the larynx should be carried out,

identifying existing dysfunction caused by the

injury, which will be the basis to plan an appropiate

rehabilitative management.

Larynx is the intersection where the processes of

breathing and swallowing take place. During the

swallowing process, the larynx moves upward and

forward, to open the esophagus for the passage of

the swallowed material. An important structure of

the larynx is the epiglottis, which is essential in

airway protection during pharyngeal phase of

swallowing (Steele and Cichero, 2014). Epiglottis is

a thin leaf-shaped cartilage functioning as a valve to

protect the larynx from aspiration of food and

liquids which pass the larynx to enter the esophagus

(Akai, 2015). Abnormal movement and position of

the epiglottis, with various etiologies from

neuromuscular diseases to traumatic injury, may

lead to aspiration of the respiratory system (Garon et

al. 2002). Even though cases of laryngeal injury, and

specifically epiglottic injury, are rare (Savinsky and

Roshchin, 2006; Sritama and Sharma, 2016)), the

injury will affect the function of swallowing,

phonation and breathing which are essentials for

daily functioning of the patient.

Sari, D., Nazir, A., Moeliono, M. and Pandji, T.

Comprehensive Rehabilitation for Epiglottis Dysfunction Due to Cut Injury of Neck with Respiratory and Swallowing Problems.

DOI: 10.5220/0009064801190123

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 119-123

ISBN: 978-989-758-409-1

119

In injury cases, the role of rehabilitation

medicine is to optimize function and regaining

quality of life after surgical repair of injury. This

case report reviews the rehabilitation program for

the airway and swallowing problems of a patient

diagnosed with neglected ‘vulnus scissum of colli

sinistra with exposed larynx and partially sliced

epiglottis’ after surgical repair.

2 CASE DESCRIPTION

Patient, a twenty-five years old male, was referred to

the PM&R department on the 15

April 2010 with

diagnosis of ‘Post-surgical laryngeal repair of vulnus

scissum at the neck with exposed larynx’. His chief

complaint was difficulty in swallowing, persistent

cough with a lot of sputum and general weakness.

History of his condition showed that on 28th

January 2010, his throat was cut in a homicide

attempt while he was sleeping in his workplace in

Palembang, a city on Sumatra, an island west of

Java. His throat was exposed, but he remained

conscious. He was brought to the nearest hospital in

Palembang, where the wound in his neck was

closed. Although the wound was closed with sutures,

fluid leaked out between the sutures everytime he

drank or ate.

In this condition he went back to Sukabumi, his

home town located in West Java region. There he

went to the local hospital, a type ‘D’ hospital

without fascilities for surgery, neither digestive,

thorax or ENT surgeons, so he was referred to Hasan

Sadikin General Hospital in Bandung, 96.4 km from

Sukabumi.

On 4th February 2010 he was admitted, and the

first surgery was done, consisting of wound

debridement, placing a tracheostomy and

gastrostomy. During surgery it was found that the

vocal cords and the base of epiglottis were partially

cut. Two days later, ENT surgeons repaired the

larynx. A nasogastric tube was inserted and nutrition

administered through the NGT. Follow up using

Rhino-Laryngo Fiberscope (RLF) was performed the

next day and showed the presence of posteriorly-

bended epiglottis and laryngeal edema. RLF was

repeated after 1 week, showing that the laryngeal

inlet was not covered completely by the epiglottis

and the sutures in the inner part of epiglottis were

exposed.

Since the patient was still in the risk of aspiration

and deconditioning, rehabilitation program was

designed to assist airway protection and prevent

deteriorating of patient condition caused by

immobilization, consisting of exercises for the

epiglottis and oromotor, exercise for chest

expansion, along with ROM exercises and

mobilization to the upright sitting position.

Because leakage from the wound still continued,

three days after the last RLF, he underwent

subsequent laryngeal repair surgery followed by

immobilization in cervical flexion position (‘nod

position’). The patient was discharged on March

19th 2010, with instructions to continue

medicamentous therapy (antibiotics, analgetics) and

exercises.

On 15th April 2010, the patient came to the PMR

department. The wound on his neck was closed, but

he still used the nasogastric tube for feeding. Patient

looked weak and thin, and on questioning told that

all he had was 6 glasses @ 250 cc of ensure milk,

one glass of cereals and one glass of fruit juice daily.

He also complained that he was not able to sleep at

night because of the persisting cough with lots of

secretion. Because of his inability to swallow, he

also complained about excessive sputum he had to

spit out. He tired easily when walking 10-15 metres,

but there was no shortness of breath. For

communication he used gestures because of his

hoarseness.

The patient was underweight with the BMI of

14,06. Blood pressure was normal with slight

increase in heart rate 130-140 beat per minute

(bpm). Tracheostomy and nasogastric tube were in

place, as was the unused gastrostomy. The laryngeal

disruption and tracheostomy also caused dysphonia.

Thorax examination showed decreased chest

expansion (1/0,5/1 cm), and sputum retention all

over both lungs, which explained his persisting

coughing. Sputum retention in the patient might be

caused by dysfunction of swallowing, aspiration and

immobility and by the use of tracheostomy

(Antonello et al, 2015). Manual Muscle Testing

(MMT) of all four extremities showed a decrease in

strength with a score of 4. Decreased muscle

strength, increased heart rate and sputum retention,

indicated deconditioning syndrome which affected

cardiovascular and musculoskeletal system (Joyner

2008; Joyner 2012). This condition explained his

complaint of fatigue (Parry and Puthucheary 2015).

Initial assessment was to measure his endurance

using the 6-minutes walking test (6MWT). Heart

rate 170 bpm was unexpected event, but then we

stopped the 6MWT. And try the next 6MWT if the

heart rate below 120 bpm. Assessment of basic

activity of daily living (BADL) used the Barthel

Index (BI) showed a low score of 19 (Katz, 2003;

Yang, 2014). Laboratory examination showed low

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

120

albumin (3,2g/dL) and low hemoglobin

concentration (12,2 g/dL), and low hematocrit

(37%). Although structural repair had been done,

RLF showed incomplete closure of laryngeal inlet

due to abnormal position and movement of the

epiglottis. This structural abnormality can cause

dysphagia with the threat of aspiration (Matsuo and

Palmer, 2008; Halczy-Kowalik et al., 2012; Steele

and Cichero, 2014).

It can be concluded that there were dysfunction

of communication, phonation (hoarseness), and

swallowing in this patient, were caused by the

dysfunctional epiglottis, aggravated by the presence

of deconditioning syndrome, malnutrition and

suspicion of aspiration.

3 INTERVENTIONS

Interventions are directed to overcome disabilities

and regain function. Rehabilitation program

consisted of exercises to improve swallowing and

respiratory function, and conditioning exercises

began with Range of Motion (ROM) exercise to

improve functional capacity. The patient was also

given a nutritional drink as meal replacement with

high-calorie and high-protein for nutritional

enhancement. At the beginning, we gave

supraglottic exercise to improve swallowing, but

then changed to double swallowing exercise due to

difficulty in doing the supraglottic exercise. Other

exercise was posture training, it was also help for

positioning while feeding.

Effective coughing, chest wall mobilization or

chest expansion, and trunk flexibility were given to

overcome respiratory problems.

Six MWT was perform to assess functional

capacity of the patient.

4 OUTCOMES

During the first three weeks the wound in the neck

began to heal, body weight increased 4 kg, but the

coughing persisted caused by secret retention in the

lungs. RLF showed an intact and posteriorly-bended

epiglottis with abnormal movements. As for the

general condition, signs of deconditioning still

showed, with a resting heart rate of 98 bpm,

respiratory rate 24 times per minute, and the score of

muscle strength of the extremities was 4.

At the end of six weeks, wound healing occured

along with increased body weight for as much as 5

kg, reaching a BMI of 17.58. There was

improvement in sputum retention, as the patient was

found to be less coughing and needing less frequent

mechanical suction. The patient could speak for 5

minutes at a time although his voice was still hoarse.

RLF showed that the epiglottis was erect in its

position, with good movement during swallowing.

General condition showed the heart rate 80 bpm,

respiratory rate 18-20 times per minute, strength of

lower extremities increased. Because of the

improved condition, the 6MWT for endurance was

done and showed a Metz of 4.40

After 7 weeks, a swallow test was done which

showed an improvement, as he could swallow

semisolid food. Swallow test with water was also

successfull. Because this function was considered

adequate, the tracheostomy and nasogastric tube

were taken out at the end of the 7th week. He could

speak, but his voice was still hoarse. Coughing was

lessening and suction was done sparingly.

The RLF showed an erect epiglottis with upward

movement and without any edema. The patient was

given a home program consisting of diaphragmatic

breathing and double swallow exercise until the

subsequent visit in the next 2 weeks. Unfortunately

the patient did not come so we could not ascertain

the final condition of the patient.

5 DISCUSSIONS

Nutritional status is important in any rehabilitation

program because its connection to general condition,

and wound healing. Since the nutritional status was

very worrying, as shown by the BMI, anemia,

hypoalbuminemia, the feeding problem should be

attended to in the first place before proceeding with

exercises and mobilization

Improvement of nutritional status was focused on

increasing caloric intake with adequate protein

composition. Nasogastric tube was still preserved as

the route of feeding until airway protection function

of the epiglottis could be assured. For a

malnourished patient with medical problems, the

caloric need could be as high as 150%-200% of

Basal Energy Expenditure (BEE). According to

Harris-Benedict formula, the BEE of this patient was

1189,2, and so the caloric need of the patient was in

the range of 1783,8 - 2675,7 kilocalories per day.

The patient got his nutrition’s need from nutritional

drink (400 calories and 9,4 gram protein per 200 ml

of serving) 5 times a day. The expected outcome

was improvement in body weight, which would

mean improvement of BMI.

Comprehensive Rehabilitation for Epiglottis Dysfunction Due to Cut Injury of Neck with Respiratory and Swallowing Problems

121

Supraglottic exercise was chosen for this patient

with epiglottic dysfunction because this technique

was designed to voluntarily close the airway and

prevent aspiration before and during swallowing,

indicated for patients with impaired laryngeal

closure (Langmore and Pisegna, 2015).

Unfortunately, the patient found it difficult to do the

supraglottic exercise. Therefore, double swallowing

exercise was conducted to strengthen the pharyngeal

muscles. This exercise will increase the efficiency of

bolus passage through the aerodigestive tract and

prevent aspiration. RLF was done several times

during these weeks to follow the function of the

epiglottis

Pulmonary rehabilitation consisted of exercise

for effective coughing, because the ability to cough

effectively is also one of the important criterion to

be fulfilled for patients with tracheostomy to be

decannulated (Antonello, 2015). To manage sputum

retention and promote airway clearance, tapping and

clapping of the chest wall were scheduled

(Makhabah and Ambrosino, 2013). Other exercises

were given for chest wall mobilization or chest

expansion and trunk flexibility. Posture training to

decrease his kyphotic posture to aid a proper

position needed for feeding was given with visual

biofeedback using a mirror (In et al., 2016)

Rehabilitation of the deconditioning syndrome is

also essential for functional recovery. The effect of

short-term exercise to improve physical fitness and

cardiovascular response in a deconditioned patient

was already proven (Shibata et al., 2012). The

patient could begin ROM-exercises of all

extremities, as ROM exercise has proven to have a

positive effect in an immobilized patient (Matsuzaki

et al., 2013). Only ROM of the neck was painfull

and restricted, needing gentle exercise.

6 CONCLUSIONS

Rehabilitation program for this patient with

epiglottic injury after surgical repair was divided in

two phases. First we had to focus on the general

condition of the patient, especially his nutritional

status, while preventing aspiration. This phase

resulted in improved nutritional status, which

supported wound healing. Next, rehabilitation

focused on the aerodigestive tract. For function of

swallowing, consisted of double swallowing

exercises and exercises to strengthen the epiglottis,

while pulmonary rehabilitation focused on airway

clearance and breathing exercises.

At the end of the 7th week, the patient was

released from the rehabilitation program after

resuming normal and safe swallowing and removal

of the tracheostomy and nasogastric tube.

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