AUCTORES
Globalize your Research
Case Report | DOI: https://doi.org/10.31579/2690-4861/286
Swami Rama Himalayan University, Department of Ent, Department of Ent Department of Ent, India.
*Corresponding Author: Shalini S Narayanan, Swami Rama Himalayan University, Department of Ent, Department of Ent Department of Ent, India.
Citation: Shalini S. Narayanan, (2023), Pediatric Oro-Pharyngeal Dysphagia Secondary to Post Diptheric Bulbar Palsy with Dilated Cardiomyopathy. International Journal of Clinical Case Reports and Reviews. 13(1); DOI: 10.31579/2690-4861/286
Copyright: © 2023 Shalini S Narayanan, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 02 January 2023 | Accepted: 10 January 2023 | Published: 23 January 2023
Keywords: quadriparesis; hypotonia; dysphonia; dysphagia; nasogastric tube
Diphtheria happens to be a serious bacterial infection which adversely affects the mucous membranes of the nose and throat. It is caused by Corynebacteriumdiptheriae which multiplies on or near the surface of the throat. It can also multiply on the skin and this usually spreads through airborne droplets or contaminated household and personnel belongings.
Diphtheria happens to be a serious bacterial infection which adversely affects the mucous membranes of the nose and throat [1]. It is caused by Corynebacteriumdiptheriae which multiplies on or near the surface of the throat. It can also multiply on the skin and this usually spreads through airborne droplets or contaminated household and personnel belongings [2]. Diphtheria can be treated with medication in the initial stages but in the advanced condition it can lead to breathing problems, heart damage and nerve damage. Studies have shown that the incidence of cardiomyopathy following diptheria is 10-20% [3][4]. The clinical features of diphtheritic cardiomyopathy become evident by the 2nd week of infection and in severe cases may present with most features [4]. Cardiomyopathy is referred to the condition where the myocardium ie., the heart muscles get affected. Dilated cardiomyopathy is the condition where the heart chambers get dilated [5]. Pediatric cardiomyopathy can be seen to affect children and teenagers of any gender, race or age. It can even be more common in infants than in older children. It has been documented that some children may show no cardiomyopathy symptoms till the time they experience a sudden cardiac arrest [6]. Severe complications of diphtheria have highlighted polyneuropathy with bulbar, respiratory as well as circulatory disturbances. Cranial nerves have also been affected thereby showing signs of quadriparesis, hypotonia, dysphonia, dysphagia and other complications [7].
A child aged 11 years/ male was initially asymptomatic but then he developed pain in the abdomen which was sudden onset, mild to moderate in intensity, generalized and continuous. The pain was relieved temporarily on taking medications. There was complaint of acute breathlessness from the last 4 days which was progressive in nature. The child also developed progressive and productive cough. The child was then brought to the emergency of HIMS for breathing support. Initial treatment was provided, once the condition was slightly stable the child was shifted to ICU. Pleural tapping and infusion dopamine was started. On the 8th day the child was shifted to pediatric ward. After that the child was referred to the Rehabilitation Unit of Speech & Hearing, Department of ENT after a month with the complaint of palatal weakness and change in voice. Laryngeal and oral cavity endoscopy revealed reduced mobility of the soft palate and paresis of vocal folds with the presence of phonatory gap. The child was on Nasogastric tube for 39 days due to respiratory distress caused due to pooling of secretions.
Detailed speech and language evaluation was carried out by the Speech Language Pathologist focusing the domains of speech and swallowing. Consent was taken from the child’s caregiver. Tools used for assessment included Milestones for Early Communication Development (MECD) for language evaluation, GRBAS for voice evaluation, Gugging Swallowing Screen (GUSS) and The Dysphagia Disorder Survey (DDS)for swallowing evaluation and AYJNIHH Intelligibility rating scale for intelligibility of speech [8][9][10][11].
The child was co-operative during the entire assessment procedure. The assessment included Oral Peripheral Mechanism Examination which showed reduced movement in the soft palate during the production of /a/ leading to a perceptual nasal emission. Fog test was done to confirm the nasal emission. Language assessment showed adequate receptive and expressive language skills in the segments of Semantics, Syntax, Morphology and Pragmatics. GRBAS was administered and was indicative of mild hoarse voice. The intelligibility rating score suggested that the speech was understood with concentration and effort especially by sympathetic listener.
Dry swallow test was done which showed delayed laryngeal elevation. GUSS suggested severe dysphagia with high risk of aspiration. NPO was advised and the caregiver was counseled about the risk of aspiration. DDS was carried out in two parts- Part 1 related factors showed poor Body Mass Index, Good independence and body postural control. Part 2 consisted of Feeding and Swallowing Competency. The child was on NG tube with the advice of NPO.
Accumulation of all the evidences led to the diagnosis of oro-pharyngeal dysphagia with palatal weakness and mild hoarse voice secondary to bulbar palsy. The child was given regular follow ups for speech and swallow therapy sessions. The child was demonstrated swallowing maneuvers – effortful swallow and super supraglottic swallow. Cold sour stimulation was given to elicit swallowing reflex. Oromotor exercises and soft palate elevation was worked on. Unilateral digital pressure was given for adduction of vocal folds.
After 2 sessions of speech and swallow therapy soft solids and thick liquid was introduced. The food was given in 3ml quantity and the child was asked to follow the maneuver with food. Swallow was effortful but it was complete and there was no oral residue, no involuntary cough as well as no gurgly voice after the swallow. After 4 sessions of speech and swallow therapy the NG tube was removed and the child was introduced to thin liquids in sips with chin tuck. Post therapy evaluation was done after 5 sessions in which GRBAS showed clinically normal voice. The intelligibility rating scale showed a score of 2 and GUSS score indicated slight dysphagia with low risk of aspiration. Dysphagia Disorder Survery –Part 1 showed poor body mass index, good independence and body postural control, soft solids were recommended in spoonful with swallowing manuevres.
Table 1: Feeding and Swallowing Competency-Dysphagia Disorder Survery (comparison pre and post swallow therapy)
Table 2: Formal test results –pre and post speech therapy
The child was discharged with recommendation for soft solids and cautious thin liquids. With an improvement in his overall condition, he was discharged from the hospital after 48 days accompanying a follow up protocol.
The clinical features of diphtheritic cardiomyopathy become evident by the 2nd week of infection and in severe cases may present with most features [12]. In India most people with diphtheria are either partially immunized or unimmunized. In our case the immunization details were not available. Presence of myocarditis has been reported in 16.5% in a retrospective case series from India [13]. In a study done on 154 Vietnamese children with the clinical diagnosis of diphtheria 13 children had diphtheritic cardiomyopathy during the time of hospital admission and 19 children had developed subsequently [12]. 8 children had even developed diphtheritic neuropathy as a late complication. Hoarseness of voice with difficulty in managing secretions were also commonly seen these children. Neuropathy develops within three to five weeks of diphtheria with the initial onset of bulbar palsy followed by cranial nerve involvement. In this case profile there was presence of palatal paresis as well as phonatory gap leading to hoarseness of voice. Along with these, presence of severe Oro-pharyngeal dysphagia confirmed Cranial nerves IX and X being affected. These findings were corroborated in the study by Piradov [7]. Another study showed the presence of bulbar palsy in all 13 with isolated palatal palsy in 7 children and progressive cranial nerve involvement was seen in 6 children leading to quadriparesis [14]. There is a dearth of literature which highlights the speech and swallowing profile specifically due to bulbar palsy in diptheritic neuropathy. Children with diphtheritic complications are challenging to manage. Often, several organ systems are affected by the infection and toxin. However, early identification would definitely help to manage the speech and swallowing complications symptomatically. It is important to focus on motivating targets. In this case working on oromotor function and elicitation of swallow reflex thereby aiding in oral feed increased the motivation in the child. Swallowing can definitely be one of most important function that can stand to uplift the overall quality of life and further promote working on other vital functions. Disease prevention through vaccination and early identification and intervention stands to be the vital keys in reducing the morbidity and mortality of this particular disease.
Pediatric dysphagia is challenging for SLPs to evaluate. A descriptive assessment should be done to identify all the overlapping conditions which include both clinical and instrumental evaluation tools. Aspiration risk can always be confirmed by the use of instrumental assessment which was not available in the present set up [15]. Prompt treatment is important for specific management of symptoms contributing to speech and swallowing disorder. This case profile will help professionals working in neurorehabilitation unit to expand the horizon of understanding with the assessment and management of challenging profiles.
Conflict of interest- The authors have no conflict of interest.
Ethical approval: All procedures performed in the study were in accordance with the ethical standards of the institutional research committee.
Informed Consent:Written informed consent was obtained from the family members of the participant included in the study.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
