Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Surgical Management of Intractable Aspiration The larynx has three distinct functions: respiration, phonation and airway protection. These functions are all very intimately related and they are exquisitely controlled. Dysfunction of the larynx can affect any or all of these functions but usually the common point is that there is aspiration. Aspiration is penetration of secretions below the level of the true vocal cords. That can be saliva, refluxate or ingested materials and it’s a normal phenomenon. Approximately 50% of normal adults will actually aspirate while they sleep. And some aspiration can be tolerated without complications. If you have an intact tracheobronchial clearance mechanism and intact mucosal defenses, you can tolerate some normal physiologic aspiration. Several factors determine the clinical significance of aspiration: incidence, volume, pH and chemical composition, consistency and the host immune status. Swallowing is a very complex event. Coordinated events move the bolus from the mouth to the esophagus and bypass the airway. The larynx has to serve as a competent sphincter. Swallowing has four stages. There is the oral preparatory stage, which involves chewing. In the oral stage, the bolus is propelled upwards and backwards along the hard palate. The pharyngeal stage is very complex and is under involuntary control. The esophageal stage is transit of the bolus to the stomach. The first part in the pharyngeal stage is nasopharyngeal protection. The soft palate elevates and blocks off the nasopharynx. Most important for this discussion is laryngeal elevation. This protects the airway and pulls the anterior aspect of the esophageal inlet upwards and anteriorly to accept the bolus. Pharyngeal peristalsis travels from superior to inferior and propels the bolus towards the esophagus. Finally, there is the pharyngoesophageal segment opening, which is a reflux neural inhibition of cricopharyngeus tone. That, combined with upward laryngeal traction and the bolus weight, sends the bolus into the esophagus past the opening of the trachea. Successful swallowing is dependent upon the successful performance of each one of these phases and most people are able to compensate for a deficiency of one or two of these stages. But the more dysfunction, the higher risk of aspiration. Once an aspirate reaches the lungs there is a type of “triple threat” described by Miller. The first effect is chemical pneumonitis. Acidic aspirates are the worst irritants, especially ones with a pH less than three. This causes irritation, which causes increased capillary permeability. Serum leaks into the alveoli and this edema compromises gas exchange. There is bacterial pneumonia, which can occur from direct contamination. This is also facilitated by damage to the mucosal defenses. Finally, there is obstruction. Mucus plugging and foreign body plugging can lead to atelectasis, which can cause further pulmonary complications and there is actually a very high mortality rate with serious aspiration. The respiratory pathology ranges from very mild bronchospasm to pneumonia, pulmonary abscess, sepsis and death. This is a variable “shopping list” of the etiologies that could possibly be causing aspiration. Most importantly, cerebrovascular accidents comprise the majority of events. In our field, we often see pharyngeal neoplasms, and post-surgical and post-irradiation dysfunctions. Evaluation always begins with a history. Look for coughing with po intake, choking, vague systemic symptoms like fever and weight loss, and history of recurrent pneumonia and, once again, vague symptoms that sometimes sound like reflux, symptoms of chronic persistent cough, throat clearing or hoarseness. It is very important to perform a complete head and neck exam. Flexible endoscopy shows the dynamic function of the larynx and sometimes you may see frank aspiration; pooling, which can be a sign that there is some sensory deficiency in the larynx; and reflux. Obtain chest x-rays. Sometimes aspiration pneumonia is found. Scintography is not regularly used, although this nuclear medicine study can show a sensitive quantitative evaluation of aspiration. Most important is the modified barium swallow. This live action study evaluates the anatomy and function of the larynx. Aspiration can be seen and, more importantly, the patient’s reaction to the aspiration. Serial exams can help gauge the patient’s potential recovery. The goals of the evaluation are to find the potentially correctable causes, surgical causes that can be fixed, obstruction, cricopharyngeal dysfunction, and conditions such as Zenker’s diverticulum. It is also important to assess the time course of this process. Is it an acute versus a chronic process? What is the patient’s potential for recovery and what is the patient’s overall prognosis? These are all important in determining how the patient should be managed, determining how aggressive or conservative the treatment should be, and assessing the overall functional status of this patient. Has this patient ever had speech? Will they ever regain their ability to speak? Will this patient ever be able to take po intake again? The primary goal of treatment is to separate the upper digestive tract from the upper respiratory tract for a short period of time or, in some cases, permanently. Eliachar, an expert on aspiration, described the criteria of a perfect procedure: it would stop the aspiration, allow safe swallowing, allow the patient to continue phonating, would be minimally invasive and would be readily reversible if the patient’s condition improved. Treatment options really depend on the underlying condition and its prognosis, as I said before. Because of that, it is difficult to compare the efficacy of different treatment modalities objectively. It is also difficult to perform randomized studies because the patients vary so widely. There are three broad categories of treatments: temporizing or adjuvant treatments, definitive reversible treatments, and definitive irreversible treatments. Medical therapy is always important. It is important to treat the acute process: antibiotics, and pulmonary toilet for lung processes. It is important to make the patient NPO, to avoid further aspiration, and to also find an alternate feeding route to maintain the patient’s nutritional status. An NG tube is commonly placed, but this may actually increase the aspiration reflux by making the lower esophageal and upper esophageal sphincters incompetent. Small, soft Dobhoff tubes are preferable. G-tubes are not preventative but they are often placed and are found to be more efficacious with the fundal plication. In some cases, a J-tube is more appropriate. True vocal cord medialization is useful in unilateral vocal cord paralysis, especially when there is a high vagal deficit, which has a motor and sensory component. This is helpful, but is rarely curative if there is a serious aspiration problem. Vocal cord injection is endoscopic. It can be done under local anesthesia and there are many different substances that can be injected lateral to the vocal cords. Gelfoam is a temporary fix. Teflon is a permanent solution; however, it is not used as frequently as it once was. Because it is very difficult to extract Teflon, precise localization is essential. Also, Teflon does, unfortunately, tend to migrate and it has been found in lymph nodes. Thyroplasty is often performed. It is an open procedure, can be done under local anesthesia, and is readily reversible. Arytenoid adduction is a procedure that can help close a larger glottic gap than a thyroplasty. Tracheotomy is very commonly performed, and provides a good airway. It does facilitate the pulmonary toilet, but does not prevent aspiration. Up to 69% of patients will aspirate past their cuffs, even if their cuffs are at the proper inflation pressure. In fact, they may promote aspiration. It tethers the larynx, eliminating elevation during swallowing. The cuff may actually press on the esophagus, obstructing it, and chronic placement has been shown to decrease sensation and cause loss of reflux glottic closure. In terms of definitive, reversible procedures, endolaryngeal stents are something that we don’t often see. They certainly function almost like a cork in a bottle. Their job is to seal the glottis and therefore they need to be used in conjunction with a tracheostomy tube. They definitively separate the digestive and the respiratory tracts. Weisberger described the first stent to be used regularly in this way, the solid silicone stent. This slide illustrates the placement method. It is placed endoscopically. Stay sutures are placed to secure it in place and, once again, a tracheotomy tube is required since this is completely occlusive of the airway. Seven patients were originally studied. Only three of those patients had no aspiration after placement of the stents. Two out of the seven were reversed successfully, There were actually two deaths due to occlusion of the tracheostomy. Elioachar, in 1987, described his stent, which is vented. This stent is different for several reasons. The main reason is that it has a one-way valve. This one-way valve, which sits at the superior aspect, allows phonation. Air can come up through a fenestrated trach and the patients can have an upper pharyngeal voice. Patients are able to eat and swallow well with these stents. The stent is secured through the trach to the neck and so tend to be safer. Their risk of becoming dislodged is less. If properly sized, these stents have been shown to have good control of aspiration. One of problems with these stents is that stents are often used that are too small. In 1999, Milo, who is in the same group, described an atraumatic, inflatable stent. In a canine model, it has been shown to be much less traumatic than the original stent. However, stents do still cause trauma because they are transglottic. The advantage of endolaryngeal stents is that they can be effective. They allow swallowing; they allow phonation if they are vented; they are placed through a minimally invasive procedure; and, they are very reversible. The disadvantage is that they are really only effective as a short-term solution. In the literature that I surveyed, the longest reported time that a stent was placed for aspiration was nine months. They are very uncomfortable for the patient and violate the endolarynx. In fact, with the softer, supposedly better inflatable tubes, which have a variable pressure, there was still a significant amount of ulceration and granulomatous change. In fact, four out of 14 of these canines had erosion all the way down to the cartilage. So there still are problems with stents and a significant risk of glottic stenosis. Epiglottic flap closure is a procedure that has been used for quite some time. It was first described by Habbol in 1972. This is an open procedure, and involves an infrahyoid pharyngotomy. Basically, mucosa is denuded in a circumferential fashion around the superglottis. So, on the epiglottis, the A-folds and the arytenoids. This is closed in two layers, with the epiglottis down against that denuded circle and the pharyngeal mucosa is rotated across to make a better seal. The original case study was a nine-year-old girl. In fact, because there was so much tension on the repair, there was a fortuitous posterior dehiscence which allowed her, because her vocal cords were below the repair, to speak. She was actually not aspirating and this procedure was later reversed successfully. This resulted in the idea that if the posterior aspect was left open, this could facilitate speech. There have been several modifications to this procedure. Some people have advocated morselizing the epiglottis to take some of the tension off. In fact, this is a modification with a scoring of the epiglottis, once again used to take some of the tension off of the closure. There are advantages with this procedure. It is very effective and allows safe swallowing. With modification, it allows phonation and is potentially reversible. The disadvantages are, once again, it involves the endolarynx and so there is potential for scarring and dysfunction of the superglottis. Also, this is an open surgery requiring general anesthesia, which is sometimes difficult in the debilitated patients who present with these kinds of problems. A vertical laryngoplasty is a variation on this same theme, described by Biller in 1983. Originally he described this in post-total and large base of tongue resection patients. It has subsequently been used in chronic aspiration patients. It is a circumferential supraglottic incision; but instead of closing the epiglottis down posteriorly, the epiglottis is folded into a tube and closed in two layers so that the flow of aspirate and food gets directed down towards the esophagus and the larynx is shielded. This actually seems very good. Patients have normal deglutition. They have almost normal speech, although there is a lot of strain. There have been reports of dehiscences with this type of procedure. Once again, the disadvantages are that it does involve the superglottis and endolarynx, and it is an open surgery requiring general anesthesia. Partial cricoidectomy has been described in a small population of patients. Krespi, in 1985, described the submucosal resection of the posterior aspect of the cricoid cartilage. This is done in conjunction with the cricopharyngeal myotomy, which serves to enlarge the pharyngoesophageal inlet. The advantage is that in post-resection patients who have a limited amount of residual pharyngeal mucosa, it gives them a larger funnel towards their esophagus. This preserves phonation since the procedure does not violate the larynx. The disadvantage is that it has a limited application. Patients who qualify for this procedure need intact sensation and laryngeal function since otherwise, this is a setup for aspiration. Tracheoesophageal diversion, otherwise known as the Lindemen procedure, was first described in 1974. This is a separation of the larynx from the trachea at about the fourth to fifth tracheal cartilage. The proximal stump is anastomosed in an end to side manner with the esophagus. This allows drainage of secretions from the larynx into the esophagus. The distal end is brought up in an end tracheostome. In the original article, this was performed on six dogs and one human subject, all of whom did well. There was little morbidity and, at least in the dogs, who had no prior neurologic deficits, there was demonstrable reversibility. The advantage is that there is 100% aspiration control. The respiratory tract has been completely separated from the digestive tract. This preserves the functional larynx and recurrent laryngeal nerves, so there is a possibility of reversal. The larynx is functional and can be monitored endoscopically to observe if function ever comes back. This can be done under local anesthesia. The disadvantages are that no natural phonation is possible. This violates the esophagus and, compared to some of the other procedures that have been developed, this is a relatively extensive surgery. With all of this in mind, Lindeman went back to the drawing board and described laryngotracheal separation. He was encountering difficulties in the anastamosis in previously high tracheotomized patients, since the proximal stump was so short. The tracheotomy was up between rings one and two, so, what he described was closure of the proximal end in a pouch, usually facilitated by resection of one of the tracheal rings and splitting of another tracheal ring up above this line. Briefly, Krespi later modified the original procedure, with the tracheoesophageal diversion with a shorter proximal stump by resecting some of this cartilage, allowing an easier bend. This procedure has been described but it is not in wide use. The proximal stump does allow pooling of secretions and several studies have shown drainage when the patient is supine. Baron, in 1980, followed a series of patients serially with endoscopy and showed that there was no adverse effect from chronic pooling in the larynx and subglottis. And, in fact, the patients did not sense this pooling. Lawless, in 1995, looked back on 21 pediatric patients who had this procedure performed, and found that many of the complaints that one might anticipate with pooling in this area, like halitosis, an increase in drooling and fistula , most importantly, actually have a very low incidence. Eisele described 31 patients with this type of surgery. He compared tracheoesophageal diversion to laryngotracheal separation. If they could get a tension-free anastomosis on a patient, a diversion was performed. If that patient had a prior tracheostomy or if they were elderly or debilitated, they received a separation. One hundred percent of these patients had no aspiration. After the procedures were done, only 55% of these patients were able to support themselves completely orally. This is not necessarily a reflection on the procedure; many times this is a reflection on the condition of the patients. Many of these patients were never able to have oral alimentation. Five patients had successfully reversals, all of whom were in the diversion group. There were three tracheocutaneous fistulas. All of these were in the separation patients who had prior tracheostomies. There is still some controversy about whether or not this is the actual pouch itself in the surgery or whether it is the fact that they had a prior tracheostomy and that there was a lot of inflammation and scar tissue at that site. Eisle prefers diversion when it is possible. Complaints regarding pooling in the subglottic pouch and that possibility that this could increase the chance of fistula over time have not really been realized, and Eisle states that that the long proximal segment makes reconstruction easier in the few patients who do qualify. Eibling,in 1995, described 34 patients. This group was very representative of these types of patients. Fifty-eight percent had a prior tracheostomy. Sixty-eight percent were already aphonic or had an unserviceable voice. All of them had laryngotracheal separations with 100% control. Thirty-three percent of these patients were able to have a normal diet and that was actually an improvement from before these procedures. There was a high incidence of post-op fistula, once again 38%, perhaps because so many of the patients had prior tracheostomies. There were two successful reconstructions. Eibling, in contrast to Eisle, favors separation. Most patients already have a tracheotomy, which makes this procedure easier and safer. The procedure itself is much easier to perform. There is no violation of the esophagus. Pooling of the secretions has not been a significant issue and few patients actually end up qualifying for reconstruction anyway. The advantages of laryngotracheal separation are that it is a less expensive surgery, requires less operative time, is technically easier and doesn’t violate the esophagus, and is possible with a prior high tracheotomy. The disadvantages are that there is pooling of secretions in the proximal pouch and the difficulties posed by the shorter proximal stump. Although most patients have tried electrolarynges, there have been some studies that have shown that patients can use TEP successfully with the Blom-Singer valve. The first such report was by Darrow in 1994, in which he described a sort of wet quality of voice, which is probably secondary to the secretions in the pouch. These patients have pretty rigorous selection criteria. They need to have minimal neurologic impairment, they need to be motivated and they need to have adequate manual dexterity and visual acuity and a large enough stoma to use this well. For completion’s sake, I am going to mention the Tucker Double Barrel tracheostomy. This is an alternative treatment for the proximal stump. Rather than send it to the esophagus or turn it into a pouch, Tucker advocated externalizing it through the sternocleidomastoid to the skin. Externalizing it through the belly of the muscle is supposed to minimize secretions. Finally, I’d like to discuss definitive irreversible procedures. The first is glottic closure. Montgomery was the first to describe glottic closure in 1975. This is performed through an open incision, a median thyrotomy, and the mucosa, in a similar vein to the supraglottic closures, is denuded in the circumferential fashion on the true vocal cords, the false vocal folds, the ventricles and the posterior commissure. This is closed in two layers with a figure of eight suture and then the true vocal folds are closed as well. This has actually been shown to be quite successful. In the early stages, and especially in patients who have good function of their larynx, there is a tendency for these wounds to come apart because the musculature fights this closure. Sasaki, in 1977, added a third layer to the closure by bringing a sternohyoid flap anteriorly and sewing it in. This gives more strength and also makes it a bit more of a watertight seal. The advantages to this are that, over the years, it has been shown to have a 95% success rate. It allows deglutition and some people say it’s potentially reversible, although there has only been one successful reported case of reversal. This causes severe glottic stenosis, which is its intended purpose, which is why it is considered, by most, to be irreversible. It is an extensive surgery and does require general anesthesia. Narrow field laryngectomy can be considered the gold standard of aspiration surgery - there is nothing more definitive to separate the respiratory and digestive tract than laryngectomy and this was the standard of care prior to the 1970s. The resection in a narrow field laryngectomy, and is less radical than the typical total laryngectomy for carcinoma. There is preservation of the hyoid, the strap muscles and as much hypopharyngeal mucosa as possible so that there is as little tension on the wound as possible. The hypopharynx is closed primarily. This is bolstered with strap muscle closure and an end tracheostome is brought through the skin. The advantage of this is that it is definitive. It can actually be performed under local anesthesia. There are quite a few disadvantages and it remains hard to justify this procedure to patients and their families. It is irreversible and is an unsavory procedure – it is considered to be amputative, and there is a stigman in that it is considered to be a disfiguring type of procedure. It violates the hypopharynx as well and is an extensive surgery. Also, with the violation of the hypopharynx, there are increased risks of fistula and pharyngeal stenosis. Some have advocated subperichondrial cricoidectomy. This was first described by Cummings in 1987 as an alternative to narrow field laryngectomy in patients with no chance of recovery of function. I’ll describe the technique very briefly. The cricoid is resected subperichondrially and is removed almost in-toto. In most descriptions, the posterior aspect is left in place so you are left with an inner perichondrial layer and the mucosa. This is transected horizontally and is closed to form two stumps. In most reports, a strap muscle flap is then placed to bolster and strengthen this closure and the perichondrium is closed over the wound. Because there is no end tracheostome, the patients do require a tracheostomy tube. There are advantages to this procedure. It has a very high success rate. It is the simplest separation procedure to perform. There is low morbidity and some people advocate that it is potentially reversible, although this is probably not the case. In fact, there are no reported reversals in the literature and a tracheotomy tube is required. Very briefly, the last things I want to mention are some new frontiers. Broniatowski, in a paper in 2001, described two patients who have had left recurrent laryngeal nerve stimulators implanted, which, through an external controller, allows dynamic glottic closure with swallowing. The patient can actually control glottic closure. These two patients, who had gross aspiration with thick liquids, had aspiration successfully prevented with stimulation. This is still under investigation by the FDA, and, if approved by the FDA, it will go into wider studies. In conclusion, chronic aspiration has substantial associated morbidity and potential for mortality. Understanding the natural history of the patient’s underlying pathology is the most important thing and is essential for surgical planning. Safe, effective, readily reversible procedures have been developed to separate the digestive and the respiratory tracts. Laryngotracheal separation is less complex than tracheoesophageal diversion and is as successful, if not more, in patients for whom reconstruction is not anticipated. Tracheotomy is not preventive but it may actually promote aspiration and early high tracheotomy complicates the potential separation procedures, leads to higher fistula rates and may make reconstruction after recovery more difficult. So, it is important to think about these things prior to performing a tracheotomy. Definitive irreversible procedures should be reserved for patients with no prior function or chance of recovery of function. Subperichondrial cricoidectomy is a viable alternative to narrow field laryngectomy. It is effective, and most reports say that it is technically simple, has lower associated morbidity and is better accepted by the patients and families. Finally, dynamic laryngotracheal closure is an exciting new development. It may revolutionize the management of intractable aspiration. Case Presentation: J.C. is a 27-year-old male with a history of cerebral palsy and profound mental retardation, who is wheelchair-bound and who does not communicate verbally. The patient had a long history of aspiration and had multiple episodes of pneumonia. He had a fundoplication and a gastrostomy tube placed several years prior to presentation. Subsequently, he had a tracheostomy placed by an outside physician. Even with the cuff inflated, the patient continued to have multiple problems with aspiration and frequent episodes of pneumonia. The patient presented for evaluation for a possible surgical procedure to correct the aspiration. It was opted to perform a laryngeal closure with formation of an end tracheostome. In January 2001, the patient underwent a laryngofissure with three-layer closure of his glottis and formation of an end tracheostome. The patient tolerated the procedure well, and was discharged on POD #3. In the post-operative period, the patient experienced markedly less aspiration, but still had some symptoms of aspiration with feeding. This aspiration was felt to be secondary to tension causing a small posterior glottic gap. In March 2001, the patient was taken back to the operating room for bilateral recurrent laryngeal nerve sections and external laryngeal closure with two figure-of-eight sutures. Exc ellent closure was achieved at that time. The patient tolerated the procedure well, and was discharged home. The patient was much improved, but still had occasional small episodes of aspiration. In June 2001, the patient was taken back to the operating room for exam under anesthesia and for endoscopic closure of a small posterior glottic chink. Since that time, the patient has done well. Currently, the patient has no symptoms of aspiration and is doing better from a pulmonary standpoint. 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