Case report
Dysarthria and dysphagia following treatment for a fourth ventricle choroid plexus papilloma

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Abstract

The present case report describes the presence of a persistent dysarthria and dysphagia as a consequence of surgical intervention for a choroid plexus papilloma (CPP). WM was a nine year ten month old male who at the time of the present study was seven years post-surgery. A comprehensive perceptual and instrumental test battery was used to document the nature of the dysarthria incorporating all components of speech production including respiration, phonation, resonance, articulation, and prosody. The nature of the dysphagia was evaluated through the use of videofluoroscopic evaluation of swallowing (VFS). Assessments confirmed the presence of a LMN dysarthria, marked by deficits in phonation, respiration, and prosody. Dysphagia assessment revealed deficits in oral preparatory, oral and pharyngeal stages of the swallow. The presence of persistent dysarthria and dysphagia in this case has a number of important implications for the management of children undergoing surgery for fourth ventricle CPPs, in particular the need for appropriate treatment, as well as counselling prior to surgery of the possible negative outcomes related to speech and swallowing.

Introduction

Choroid plexus papilloma (CPP) is a rare benign lesion of the central nervous system (CNS) constituting less than 1% of all primary intracranial tumours.[1], [2], [3] They occur most commonly during childhood and represent approximately 4% of intracranial neoplasms during childhood. These tumours arise from the ventricular choroid plexus and are typically located in the lateral, third or fourth ventricles. During childhood the tendency is for CPP to be located in the lateral ventricles with the fourth ventricle an infrequent site, particularly in very young children.[1], [2], [4], [5] Treatment for CPP involves surgery only, with the aim of surgical intervention being gross total resection.[1], [3], [6] If total excision of the tumour is achieved, recurrence is rare with survival rates at both one- and five years reported to be 67%.7

Significant neurological sequelae after surgery such as epilepsy, cognitive impairment, pyramidal tract dysfunction, sensory disturbances, and cranial nerve dysfunction involving nerves II through to X in varying combinations have been recognised.2 Despite the identification of cranial nerve damage in the CPP population there has been no specific documentation of speech and swallowing deficits. Both dysarthria and neurogenic dysphagia can result from dysfunction of the lower cranial nerves (VII XII) or pyramidal dysfunction,[8], [9] therefore it would not be unexpected that a child treated for CPP would develop either of these disorders post-operatively.

While there are no studies to date that report specifically on the nature of the dysarthria and/or dysphagia in children treated for CPP, there are a number of case reports that document these sequelae in children treated for tumours arising from, or impacting on the fourth ventricle.[10], [11], [12] These reports, however, do not offer comprehensive descriptions of either the dysarthria or dysphagia, and in all cases resolution is indicated. The present case study in contrast documents a surgical case who presents with persistent and long-standing dysarthria and dysphagia as long-term consequences of surgery for CPP. The aim of the present study is to provide a detailed profile of the persistent speech and swallowing deficits of this case using a comprehensive perceptual and instrumental test battery.

Section snippets

Case report

The case was a 9 year and 10 months old male, WM managed surgically 7 years prior for a fourth ventricle CPP. He presented to medical staff at 2 years 6 months of age with a 14-month history of general irritability, which had worsened over the 10 days preceding medical attention. Simultaneously, it was observed that he developed a head tilt to the right and an increasingly unsteady gait and had a 2-day history of episodes of vomiting. A neurological examination identified papilloedema,

Perceptual speech assessments

A perceptual profile of the WM’s speech was compiled through administration of four different perceptual assessments under standard conditions in quiet surroundings. The perceptual assessments included: The Frenchay Dysarthria Assessment (FDA);13 a perceptual analysis of a speech sample the ‘Grandfather Passage’;14 the Children’s Speech Intelligibility Measure (CSIM);15 and the sentence task of the Assessment of Intelligibility of Dysarthric Speech (AssIDS).16 Performance on the FDA and

Videofluoroscopic evaluation of swallowing

The videofluoroscopic evaluation of swallowing (VFS) study was recorded on high quality VHS tape and then rated individually by two experienced speech pathologists according to the 35 deviant swallowing dimensions described by Morgan et al.23 Three consistencies of food were assessed during the VFS and they were puree, soft chewable, and thin liquid at bolus volumes of 3 and 5 ml. Only the lateral view of the swallow was observed and rated. The results are reported in Table 3 with the swallow

Discussion

Perceptually, WM’s speech disorder was characterised predominantly by a mild reduction in overall speech intelligibility and marked by deviant phonatory quality with some respiratory and prosodic deficits also evident. Instrumental assessment of the components of the speech production mechanism confirmed the phonatory impairment, as well as identifying deficits in velopharyngeal and tongue function. Compromised swallowing function has also been a long-standing problem following WM’s surgery and

Conclusion

The current case report describes the nature of a persistent dysarthria and dysphagia in a child surgically treated for CPP. Medically, a number of the neurological sequelae have indicated damage to the lower cranial nerves following surgery for this subject and many of the deviant speech and swallowing features in this case can be attributed to a lesion in this region. While it is acknowledged that there are limitations to comparing a paediatric case to adult dysarthria criteria, the results

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