Laryngology Seminar
R3 蘇鉉釗
2004-3-31
Management of Intractable Aspiration
Laryngeal function: phonation, respiration, protection
Laryngeal protective mechanism:
1. Epiglottic tilt: pressure from the bolus above, downward pull for TE muscle,
pressure of tongue bass moving posteriorly&laryngel elevation  prevent entry of
food into laryngeal vestibule and facilitate food into pyriform sinus
2. Laryngeal closure: adduction of vocal folds, medializaion of ventricular and AE
folds, polysynaptic brainstem reflex
Aspiration: laryngeal penetration of secretion (eg. Saliva, ingested liquids or solids,
reflux of gastric content) into the trachea below the level of the true cord
Timing of aspiration: prior/during/after swallowing
Aspiration: silent or symptomatic, depend on intact afferent input of cough reflex
(sensation of laryngeal mucosa)
Aspiration occur in healthy people (50%, during sleep), tolerated without
complication (tracheobronchial clearance&defense mechanism), severity depend on
volume and character of aspirated material (eg. PH)
Chronic or intractable aspiration entails repeated episodes of aspiration with
respiratory complications (bronchospasm, airway obstruction, tracheitis, bronchitis,
pneumonia, pulmonary abscess, sepsis)
Etiology
Identify the etiology  predict long-term prognosis and guide management decisions,
reversible or irreversible (Table I)
Evaluation
 Detailed medical history, prior injury, surgery
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Episodes of chocking and coughing associated with oral intake
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Patients with trachostomy  tracheal secretion with copious salivary
consistency or food content (color marking of saliva)
Physical examination: complete head and neck/neurologic assessment on
function of the upper aerodigestive tract
FEES: pooling and spillage of saliva of food into the laryngotracheal complex
VFSS
CXR, general condition, patient or family expectation
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Aspiraiton Classification: I~IV
Nonsurgical management: appropriate antibiotics for infectious complication,
aggressive pulmonary therapy, discontinue of oral intake (NG feeding or gastrostomy),
reduced GER, reduced salivation and frequent suction of oral cavity and oropharynx
Surgical management
Ideal intervention for aspiration
1. effective in preventing aspiration
2.
3.
4.
5.
allow safe swallowing
allow phonation
be minimally invasive, local anesthesia
be reversible
Adjuvantive surgical procedures: clinical significant aspiration (level III~IV)
Tracheostomy
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Traditional management of chronic aspiration  tracheostomy + enteral feeding
Cameron et al: With use of blue dye  66% of tracheostomized patients in ICU
aspirated
Tracheostomy impair swallowing: restricted laryngeal elevation, compression of
esophagus due to inflated cuff
Sasaki et al: Trachesotomy breathing  densenitizaion and loss of reflexive
glottic closure
Effective pulmonary toilet, not a permanent solution for chronic aspiration
Cricopharyngeal Myotomy & Laryngeal Suspension
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Failure of the sequential relaxation of CP, combined procedure with supraglottic
laryngectomy, base of tongue or pharynx resection
Upper esophageal manometry
Transect distal inferior constrictor, CP, upper circular esophageal fiber
Vocal Cord Medializaion
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Vocal cord paralysis combined with a laryngeal sensory deficit (eg. high vagal
lesion)
Unreliable method to prevent chronic aspiration
Definitive Procedures: all definitive procedures require a tracheostoma
Endolaryngeal Stents
 Weisberger et al.: solid silicone laryngeal stent, placed endoscopically and
secured transcervically with sutures; 24/25 successfully treated, eight with
resumption of voice, four >1 year, laryngotracheal injury or stenosis (Fig1)
 Eliachar: vented silicone laryngeal stents(Hood Laboratories, Pembroke, MA,
Fig2)
1. Main body is a hollow tube designed to adhere to the inner configuration of
larynx and upper trachea, pressure over mucosa <20~30 mmHg
2. Inserted through a tracheostomy and secured by a flexible strap of silicone
extending from the tracheostomy tract above the tracheostomy tube
3. Domelike projection at top of stent may be incised for phonation
33 improve after stent insertion, 3 weeks to 13 months, leakage resolved by change
larger stent, granulation formation (+)  short-term use is recommended
Advantage: easily introduced, properly sized for patient to prevent aspiration
Disadvantage: lack uniform success by leakage or extrusion, potential
endolaryngeal injury or displacement with airway obstruction
Laryngeal Diversion and laryngotracheal separation
 Patient does not tolerate laryngeal stent, has a reasonable potential for
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improvement
Lindeman et al (1975): laryngeal diversion, potential reversibility; midline skin
incision just below circoid to suprasternal notch  trachea exposed and freed
circumfrentially for 4 cm length with preservation of bilateral RLN  trachea
separated between 3rd and 4th ring  anterior esophagotomy  end-to-side
tracheoesophageal anastomosis  permanent tracheosotmy (Fig3)
Krespi et al: modification of Lindeman procedure, previous high tracheostomy,
submucosal dissection of the lower posterior cricoid cartilage at its lamina and
upper tracheal rings  anterior mucosal flap  diverted into the esophagus
(Fig4)
Baron and Dedo (1980): laryngotracheal separation by closing the proximal
stump, supine position empty pooling secretions in larynx/subglottic pounch
(Fig5)
Tucker (1980): diversionary “double-barrel” tracheostomy, proximal tracheal
stump as controlled fistula (Fig6)
Eisele et al (1988): 31 patients, 100% success rate, 5 patients reversal with
adequate airway and voice
Tracheoesophageal diversion  patients with no previous or low tracheostomy
Laryngotracheal separation  previous high tracheostomy, prevent high tension
anastomosis from the trachea stump to esophagus, difficulty of mobilization a
tracheal stump (local inflammation, scar tissue, fibrosis)
Advantage: preservation on the larynx, reliabililty, potential for reversal
Disadvantage: loss of phonation, recurrent laryngeal nerves injury, need for open
operative procedure, fistula formation, technically difficult in the presence of a
previously established tracheostomy
Glottic/Supraglottic Closure
 Habal and Murray: epiglottic flap for glottic closure via pharyngotomy, denuding
the edges of the epiglottis, AE folds, and arytenoids  cut epiglottic mucosal
surface sutured with AE folds-arytenoid complex  Rotating pyriform sinus
mucosal flaps to cover rough surface of epiglottis (Fig7)
Determining the endoscopic anatomy of epiglottis is critical for proper patient
selection (length, width, anteroposterior dimension)
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Stome and Fried: modification to lessened dehiscence of the flap posteriorly
1. diminishing the tensile strength and elasticity of the epiglottic cartilage by
linear striations or wedge excision
2. severing the hypoepiglottic and thyroepiglottic ligaments
 Biller et al (1983): vertical laryngoplasty, usefulness in patients s/p total
glossectomy (Fig 8)
 Montgomery (1975): laryngofissure  true and false folds, ventricles and
posterior glottis are denuded of mucosa  nonabsorbable monofilament sutures
approximate the glottic surface & absorbable sutures for false cord (Fig 9)
 Sasaki et al: modified glottic closure with interposition of a sternohyoid
muscular flap to reinforce the closure and prevent posterior leakage (Fig 10)
 Pototschnig et al(1996): preoperative botulinum toxin A paralyze intrinsic
laryngeal muscles to hinder movement during wound healing + glottic closure;
success in 6 patients
Advantage: potential reversibility in supraglottic closure, high success rate in
glottic closure (95%)
Disadvantage: loss of phonation, open operative procedure, tracheostomy
Subperichondrial cricoidectomy
 Eisele (1995): expose anterior cricoid cartilage  outer cricoid perichondrium is
elevated to posterior cricoid lamina  inner perichondrium is elevated
circumferentially and be transected with mucosa horizontally, inverted and
closed  subglottic pouch  buttressed by strap muscles (Fig 11)
Advantage: high success rate, simplicity, low morbidity, be performed in local
anesthesia
Disadvantage: fistula into upper trachea, tracheostomy, designed to be irreversible
Laryngectomy (Fig 12)
 Before 1970, laryngectomy  surgical tx for chronic aspiration
 Total narrow field laryngectomy  gold standard in terms of definitive treatment
 Preserve hyoid, strap muscles, as much hypopharyngeal mucosa  prevent
pharyngeal stenosis
 Trend of be replaced by subperichondrial criboidectomy
Conclusion: an understanding of the pathophysiology of aspiration, knowledge of
the wide range of possible solution is essential in optimal tx(Table II)
Referrence:
Eisele DW. Chronic aspiration. In Cummings CW, ed. Otolaryngology-Head & Neck Surgery. 3rd ed.
St. Louis: Mosby, 1998.
Miller FR and Eliachar I. Managing the aspirating patient. Am J Otolaryngol. 1994;15:1-17
Baron BC, Dedo HH: Separation of the larynx and trachea for intractable aspiration. Laryngoscope
90:1927, 1980.
Eibling DE, Snyderman CH, Eibling C. Laryngotracheal separation for intractable aspiration: a
retrospective review of 34 patients. Laryngoscope. 1995;105:83-85.
Montgomery WW: Surgery to prevent aspiration. Arch Otolaryngol Head Neck Surg 101:679, 1975.
Sasaki CT and others: Surgical closure of the larynx for intractable aspiration, Arch Otolaryngol Head
Neck Surg 106:422, 1980.
Pototschnig CA et al. Repeatedly successful closure of the larynx for the treatment of chronic
aspiration with the use of botulinum toxin A. Ann Otol Rhinol Laryngol. 1996;105:521-4
Eisele DW and others: Subperichondrial cricoidectomy: an alternative to laryngectomy for intractable
aspiration, Laryngoscope. 1995;105:322-5
Weisberger EC, Huebsch SA: Endoscopic treatment of aspiration using a laryngeal stent, Otolaryngol
Head Neck Surg 1982; 90:21-5
Eliachar I and others: A vented laryngeal stent with phonatory and pressure relief capability,
Laryngoscope 1987;97:1264