The surgical management of chronic aspiration BackgroundThe interplay of several complex mechanisms is required to achieve a balance in the physiologic functioning of the upper aerodigestive tract. When these mechanisms are in optimal functional capacity, voluntary and involuntary neuromuscular control allows the individual to perform the acts of phonation, respiration, swallowing, and airway protection. These functions are critical to the sustained well-being of the individual, and a breakdown of any of these functional areas can produce disease with resultant morbidity and mortality. Once medical management fails, surgical options may be considered as a lifesaving intervention.

An image depicting a laryngeal cleft can be seen below.

Type II laryngeal cleft. Note the abnormally posterior position of the endotracheal tube in the glottis.

History of the ProcedureThe surgical management of chronic aspiration is based on the concept of the shared upper airway for the functions of swallowing and respiration. Before 1972, laryngectomy was routinely chosen to separate these functions in the setting of chronic aspiration. This practice was considered less than ideal because voice and supraglottic respiration are lost. Further, the procedure is irreversible.

In 1972, Habal and Murray described a laryngeal closure procedure in one patient that involved creation of an epiglottic flap to close the larynx.[1] In 1975, Lindeman described his experience with a reversible technique in which he diverted the larynx to the esophagus and the trachea to the neck as a stoma in a canine model.[2] He subsequently performed this procedure on a patient with a paralyzed larynx. Modifications have been described (eg, laryngotracheal separation [LTS]), including several by Lindeman.

Since then, as diagnostic and therapeutic techniques have become more sophisticated, more specific procedures have been developed to address specific pathology. These procedures included laryngeal-specific techniques, such as vocal cord medialization, total/partial cricoidectomy, and laryngeal suspension. Alimentary procedures, such as feeding gastrostomy and jejunostomy, cricopharyngeal myotomy, and gastric fundoplication, are also useful. Chronic aspiration of excessive oropharyngeal secretions may be controlled via surgical control of salivation.

ProblemChronic aspiration is defined as recurrent episodes of liquid or solid materials that pass below the level of the vocal cords. Surgery is indicated when intractable

aspiration with life-threatening sequelae does not respond to conservative medical management.

EtiologyThe etiology of chronic aspiration is multiple and reflective of the functions of the larynx in airway protection, swallowing, phonation, and respiration. A disorder that has an effect on neurologic control, muscular strength, or local anatomy of the upper aerodigestive tract can affect these functions with resultant chronic aspiration.

In the adult population, the most common etiology is neurologic sequelae from a stroke (infarct or hemorrhage). In this circumstance, aspiration is usually secondary to the loss of cough and swallow reflexes. Closed head injuries, anoxic encephalopathy, and CNS depression due to intoxication may also produce aspiration.

Degenerative neurologic diseases (eg, multiple sclerosis, Parkinson disease,amyotrophic lateral sclerosis), neuromuscular diseases (eg, myasthenia gravis, muscular dystrophies), and peripheral neuropathies (eg, cranial nerve disorders,Guillain-Barré syndrome) can result in chronic aspiration.

Neurogenic aspiration is commonly differentiated into lower and upper motor neuron etiology. Upper motor neuron pathology presents with aspiration that is characterized as straining or strangling in nature; whereas, lower motor neuron disease is associated with flaccid paralysis and aspiration of liquids. Intracranial complications of infection and/or neoplasms may produce aspiration due to neurologic devastation, either directly or from treatment (ie, radiation, surgery).

Pharyngeal and esophageal disorders, such as laryngopharyngeal andgastroesophageal reflux, cricopharyngeal spasm, strictures, Zenker diverticulum, achalasia, and postradiation/postsurgical changes for neoplastic processes, may result in aspiration.

Lastly, the pediatric population may have aspiration as a result of congenital anatomic abnormalities, such as laryngeal clefts and tracheoesophageal fistulas, as well as sialorrhea and many of the previously noted etiologies.[3]

PathophysiologyAspiration is not always a pathologic process. A small amount of aspiration is normal. When the normal mechanisms for airway clearance (ie, coughing, cilia) are present, they protect the airway from complications.

Pathologic aspiration is marked by pulmonary complications (eg, aspiration pneumonitis/pneumonia). A breakdown in airway clearance mechanisms and/or in respiration, phonation, or swallowing mechanisms can result in pathologic aspiration. The pathologic processes responsible for the breakdown of these mechanisms have been previously discussed.

PresentationThe clinical presentation of chronic aspiration is variable and nonspecific. Clinical symptoms suggestive of chronic aspiration include choking, coughing, fever, dyspnea, dysphonia, frequent throat clearing, chest pain, dysphagia, odynophagia, tachypnea, wheezing, rales, and emesis. The pediatric population may have many of these symptoms, as well as stridor, failure to thrive, apneic episodes, and regurgitation of feedings. Further, the presentation of chronic aspiration may be so-

called silent aspiration with no presenting symptoms or signs until complications develop. See the image below.

Base of tongue thyroglossal duct cyst in infant presenting with dysphagia and aspiration without associated stridor or airway obstruction.

IndicationsSurgical intervention for intractable aspiration is indicated when life-threatening complications ensue and conservative measures do not adequately control episodes of aspiration.

Relevant AnatomyThe upper aerodigestive tract (from the oropharynx to the larynx) allows for separating the various functions of these areas while also coordinating them. These functions are respiration, phonation, swallowing, and airway protection via cough reflexes/ciliary clearance.

The pertinent anatomy and physiology of the oropharynx is related to its function in speech and swallowing. The borders of the cheeks and lips define the mouth. The interior of the mouth contains the dentition, mucosa, salivary gland apertures, and tongue. The hard and soft palate forms the roof of the mouth. The most posterior portion of the soft palate or velum is extremely important in preventing the nasopharyngeal reflux during swallowing. The anterior and posterior muscular pillars formed by the palatoglossus and palatopharyngeus muscles (which form the tonsillar fossa) are important functional and anatomic landmarks.

The pharynx is bordered by mucosa that covers the constrictor muscles of the oropharynx and the hypopharynx. The larynx is bounded superiorly by the upper tip of the epiglottis and inferiorly at the lower border of the cricoid cartilage. The laryngeal mucosa is draped over a cartilaginous framework, which includes the epiglottis, the aryepiglottic folds, the false vocal folds, the cuneiform, corniculate and arytenoid cartilages, and the true vocal folds (which include the vocalis muscles and membranous coverings). The major cartilaginous framework, from superiorly to inferiorly, is the thyroid cartilage (which houses the glottis proper) and the cricoid cartilage. The hyoid bone also serves as an attachment to which the larynx is suspended.

Deglutition is a complex act that is under both voluntary and involuntary neural controls. Swallowing is typically divided into 4 stages. The first 2 stages are under voluntary control, except in the newborn period when the swallowing reflex is regulated at the level of the brain stem. The second 2 stages are reflex actions. The afferent limb of this reflexive action consists of sensory and proprioceptive fibers in the glossopharyngeal, trigeminal, and superior laryngeal nerves that supply the laryngeal and pharyngeal mucosa. Impulses are transmitted to the swallowing center in the floor of the fourth ventricle. The efferent limb consists of general visceral efferent fibers that begin in the nucleus ambiguous and descend through the vagus nerve to supply the laryngeal and pharyngeal musculature.

The preparatory phase consists of the ingestion of food into the mouth and the formation of a food bolus after chewing and salivary mixing. The bolus is held between the hard palate and anterior two thirds of the tongue, while the tongue base and soft palate act to close the pharynx until the bolus is fully prepared.

The oral phase begins with the elevation of the anterior tongue as it meets the hard palate and the food bolus is pushed posteriorly into the pharynx. The preparatory and oral phases are under voluntary control. Once the anterior tonsillar pillar is met, the pharyngeal phase is initiated. The pharyngeal constrictors, the palatopharyngeus, and the closed velum interact to essentially squeeze the bolus down the pharynx and the hypopharynx toward the esophagus.

Once the esophageal phase begins, respiration ceases with laryngeal closure; the epiglottis, aryepiglottic folds, false vocal folds, and true vocal folds close. Concomitantly, the soft palate meets the posterior pharyngeal wall in the nasopharynx, thus closing the nasopharynx during the swallow. The cricopharyngeus muscle relaxes, and esophageal peristalsis completes the swallow.

The cough reflex is mediated via the sensory receptors of the airway located within the respiratory epithelium from the larynx to the terminal bronchioles. The medullary cough centers control the reflex with afferent and efferent limbs of the reflex via cranial nerve X and, to a lesser extent, cranial nerves V and IX.

Cough can be voluntarily initiated without stimulation from other afferent pathways. The efferent fibers of the cough reflex leave the medullary cough center through the phrenic and spinal motor nerves to the diaphragm and intercostal muscles, respectively. The abdominal and pelvic muscles also participate in the efferent limb. The cough mechanism is initiated with a rapid, high-volume inspiration via maximally abducted vocal cords and intrathoracic expansion. This results in a high-pressure gradient once the vocal cords adduct, the supraglottic larynx closes, and the expiratory muscle contracts. This compressive coughing is primarily mediated through the closure action of the false vocal folds, which act as a sphincter. Finally, the glottis opens, accompanied by expiration of a high-pressure air column that carries expectorated materials from the airway.[4]

ContraindicationsContraindications to surgical intervention for chronic aspiration are procedure specific and are discussed with each procedure. Generalized surgical contraindications include bleeding diatheses, anesthetic contraindications, poor pulmonary reserve, and/or expectation of return of normal function.

Imaging Studies A modified barium swallow technique with videofluoroscopy examines upper

aerodigestive function. This study is considered the criterion standard in the evaluation of swallowing function.

During the study, the patient swallows food and liquids of varying consistency mixed with a small amount of barium while in the fluoroscopy suite.

The image is adjusted to view the lips, the soft palate, the posterior pharyngeal wall, and the cervical esophagus.

Ultrasonography can be useful in studying the oral swallowing phase. This imaging study avoids the use of radiation and allows the

visualization of the actual tongue surface instead of the swallowed bolus. Abnormalities of tongue movement, tongue and palate approximation,

and hyoid elevation can be detected. Radionuclide scintigraphy can measure the severity of aspiration.

To facilitate this imaging study, the patient swallows a small amount of water with technetium-99m.

While the patient lies under the scintillation camera with a computerized counting device, the radiologist compares the amount of radioactive material entering the lung to the total radioactive count and calculates the percentage of aspiration.

Diagnostic Procedures The functional endoscopic evaluation of swallowing involves positioning a

flexible nasopharyngoscope just posterior to the soft palate. This position allows for observation of the hypopharynx and the larynx, while the patient is fed various consistencies of food dyed with coloring to aid visualization. Sensory testing can be performed using a calibrated puff of air delivered to the supraglottic larynx. See the

images below. Type I laryngeal cleft with posterior penetration

during functional endoscopic evaluation of swallowing (FEES).Type II laryngeal cleft. Note the abnormally posterior position of the endotracheal tube in the glottis.

Parameters that can be evaluated include pharyngeal pooling, premature spillage, laryngeal penetration, aspiration, and residue.

The benefits of this technique over the rehabilitative swallow study include the ability to assess pharyngeal sensation and the absence of radiation exposure. The disadvantages include that the test is mildly invasive. In addition, evaluation is limited to the events immediately before and after the swallow event, with the preparatory and oral phases of the swallow only indirectly evaluated and no evaluation of the esophageal phase.

Manometry uses a catheter passed through the pharynx into the esophagus to measure the pressure changes. When used with videofluoroscopy, this procedure can be helpful in identifying cricopharyngeal dysfunction.

Medical TherapyMedical therapy frequently requires the interdisciplinary cooperative efforts of medicine, otolaryngology, gastroenterology, speech therapy, radiology, physiatry, and neurology specialists.

Usually, the first step in the medical management of chronic aspiration is the treatment of bronchopulmonary complications (eg, pneumonia). This treatment may entail antibiotic therapy that covers anaerobic and pseudomonal species and intubation for ventilatory support and intensive care. Once the patient stabilizes, the severity, source, pathologic etiology, and chronicity of the aspiration is determined.

Until a swallowing evaluation is completed, allow the patient nothing by mouth (NPO). Consider alternative methods of alimentation that use the gut (when functional). Methods include gastrointestinal feeding tubes via the nose or mouth and percutaneous gastrostomy or jejunostomy. Since alimentary feeding tubes do not eliminate the risk of aspiration (as with orogastric/nasogastric tubes) and actually may increase the aspiration by elimination of the protective action of the esophageal sphincters, reflux precautions must be strictly followed. Reflux precautions include placing the bed in a high Fowler position, especially during and after feedings; maintaining slow drip rather than rapid bolus feedings (or small frequent feedings); and administering medication.

Antiemetics, H2 antagonist, and proton pump inhibitors are frequently used. Hyperalimentation may be used in individuals who are not alimentary feeding candidates. Pursue aggressive pulmonary toilet (including frequent suctioning) in both intubated and nonintubated patients with aspiration.

Surgical TherapyTracheotomy

Tracheotomy is indicated in both chronic aspiration and pulmonary complications requiring sustained ventilatory support. This procedure is also indicated in relief of upper airway obstruction, in prolonged need for ventilatory support, obstructive sleep apnea, and pulmonary hygiene.

A tracheotomy does not prevent aspiration. In 1999, Schonhofer et al reported a 30% aspiration rate in patients who were tracheotomized.[5] The presence of a tracheotomy tube can increase aspiration risk via limitation of laryngeal elevation and anterior-superior excursion during swallowing.[6] A cuffed tracheotomy tube further increases this risk and the risks of mucosal ulceration, tracheal stenosis, and chondritis. These risks have been minimized with the advent of high-volume, low-pressure cuffs.

After achieving an adequate level of general endotracheal anesthesia, the patient is positioned with a shoulder roll to assist with obtaining adequate neck extension for exposure. The patient is usually then prepared and draped in a sterile fashion. Local anesthetic containing epinephrine is injected along the proposed incision site. The neck is then prepped and draped in a sterile fashion.

An incision is made either vertically in the midline or horizontally in a skin fold centered halfway between the cricoid cartilage and the sternal notch in most patients. The incision is carried through the skin, subcutaneous tissue, and platysma muscle to the level of the strap muscles. The relatively avascular midline raphe of the strap muscles is identified and strap muscles are retracted laterally. The thyroid isthmus is either retracted or divided, depending on its position in relation to the tracheal rings.

In adults, a cricoid hook can be used to assist with superior retraction. This is not advised in young children due to the risk of injury to the cricoid cartilage. A variety of anterior tracheal wall incisions can be used. In children, before making an incision, safety retraction sutures are placed on either side of the midline at the third/fourth

tracheal ring level, then the incision is made vertically through the third, fourth, and sometimes the fifth tracheal ring.

The safety sutures are kept long, labeled right and left, and at the conclusion of the surgery are secured to the anterior chest wall on either side for use in case of accidental decannulation. In adults, one common method is to create an anterior window, removing the central/anterior portion of the third and sometimes the fourth tracheal rings. Alternatively, instead of removing the window, it is left with an inferior attachment and sutured to the skin. Both in children and in adults, the edges of the tracheal incision can be sutured to the skin in all 4 quadrants as a method to decrease the time to stomal maturation and decrease the risk of false passage creation in the event of the accidental decannulation.

At this juncture, the endotracheal tube is withdrawn, and a tracheotomy tube is inserted. The tracheotomy tube is appropriate to both the patient's age and the size of the trachea. It is fastened to the patient using tracheotomy tape with a finger breadth of room under the tie. Foam padding may be placed under the ties to prevent skin breakdown. In adults, the tracheotomy plate can be sutured to the skin.

Complications include wound infection, bleeding, hematoma, tracheotomy tube plugging, accidental decannulation, and pneumothorax.

Postoperative care includes frequent suctioning with precautions to prevent decannulation, especially until the tract has matured, usually within 3-7 days. Tracheostomy site cleaning helps to prevent development of granulation around the tube. As part of home discharge planning, home caregivers need to be educated regarding tracheotomy care, cleaning, and emergency procedures.

Laryngectomy

Billroth performed the first laryngectomy in 1873 for laryngeal carcinoma.[7]Laryngectomy was once the mainstay of surgical intervention for aspiration. However, the loss of phonation, laryngeal respiration, and irreversibility of the procedure has limited its use. In 1990, Dedo, who no longer performs laryngotracheal separation (LTS) for aspiration because reconnection was not accomplished in his population, stated that the inability of patients who underwent LTS to phonate and the inability to insert voice prosthesis were considerations in his decision to return to laryngectomy for treatment of aspiration.[8]

Laryngectomy is most commonly used for aspiration when life-threatening aspiration occurs or is at high risk of occurring following surgical management of head and neck tumors (especially of the oropharynx) and occasionally in progressive neurologic conditions that have irreversibly impaired swallowing. Laryngectomy would not be the treatment of choice when a reasonable chance for functional improvement in the patient’s swallowing function exists.[9]

The first decision in preparing a patient for laryngectomy for chronic aspiration is to choose an incision type. The apron flap incision (which incorporates the previous tracheostomy stoma) is commonly used as a tracheotomy and is often performed in patients with chronic aspiration. The incision starts from the mastoid tip to the level of the stoma, then curves upward to the contralateral mastoid tip following the edge of the sternocleidomastoid (SCM) muscle for the vertical portion and a natural skin crease at the horizontal anterior neck portion. The skin flaps are then elevated in the subplatysmal plane.

In general, a narrow field of resection is performed, and the hyoid, strap musculature, and the hypopharyngeal mucosa are preserved.[10] The larynx is skeletonized after

separation of the strap muscles in the midline and division with ligation of the thyroid isthmus. Following this step, the thyroid is released from the ligamentous attachments to the larynx and the trachea.

The posterior border of the thyroid cartilage is exposed, and the inferior constrictor muscle attachment to the thyroid cartilage is identified. Subsequently, the attachment is released along the ala of the thyroid cartilage. The superior laryngeal nerve with accompanying artery and vein are ligated and divided bilaterally. The superior horn of the thyroid cartilage is identified, and the piriform sinus mucosa is dissected free of the thyroid cartilage bilaterally. The thyrohyoid membrane is incised along the inferior border of the hyoid, and the larynx is mobilized. The trachea is transected at the level of the previous stoma, and the posterior trachea along with the cricoid cartilage is carefully separated from the esophagus. The anterior wall of the distal tracheal segment is then sutured to the skin with a heavy suture, and an armored tube is placed.

The pharynx is entered via the piriform sinus or the vallecula. Alternatively, the pharynx may be entered at the arytenoids, with a limited infrahyoid pharyngotomy performed. This allows preservation of the pharyngeal mucosa in vallecula, aryepiglottic, and postcricoid areas. However, the classic incision is carried along the walls of the sinuses medially and along the vallecula and epiglottis superiorly. Once the level of the cricoid cartilage is reached, the incisions are joined (ie, superior and inferior incisions), and the larynx is removed. The pharynx is then closed using an inverted running-type Connell stitch with 3-0 Vicryl over a nasogastric tube. The constrictor muscles are sutured in a similar fashion to provide for a second-layer closure.

Suturing the skin edges to the tracheal mucosa without tension forms the permanent tracheostome. This may require defatting of the adjacent skin and/or subcutaneous tissue. Lastly, the wound is closed in layered fashion with reapproximation of platysmal, subcutaneous, and epidermal layers. If a tracheotomy was originally present in the skin flap, excision of the scarred tissue is required, and the defect is repaired as meticulously as possible.

Complications include pharyngocutaneous fistula, infection, stomal stenosis, and subcutaneous hematoma.

For postoperative care, the wound drainage is monitored. Drains are discontinued when minimal drainage is noted. Wounds are covered with topical antibiotic ointment. Sutures are removed in 7-10 days. Care of the tracheostome is as previously noted. Systemic antibiotics are administered postoperatively for 3 doses. Prior to discharging the patient from the hospital, methylene blue or radiographic swallow studies may be performed to exclude subclinical pharyngeal or esophageal leakage.

Phonation may be restored postoperatively with minimal aspiration risks by using the Blom-Singer prosthesis via tracheoesophageal puncture.

In 1997, Krespi and Blitzer reported on 10 patients who were treated with this technique after other procedures had failed for aspiration; this technique was successful in all 10 patients.[11]

Laryngeal Suspension

Suspension of the supraglottic laryngeal structures may be performed. Laryngeal suspension allows for easier swallowing via a wider hypopharynx and guards against

glottic penetration during swallowing. This procedure allows the continuance of normal respiration, phonation, and swallowing.[12, 13]

Indications for laryngeal suspension include aspiration following supraglottic and/or hypopharyngectomy.

Contraindications to laryngeal suspension include life-threatening aspiration. (This procedure is usually performed in conjunction with supraglottic laryngectomy and/or hypopharyngectomy.)

The anterior neck is prepared and draped in a sterile fashion. The skin is incised at the level of the thyroid cartilage and is carried to the platysma. Subplatysmal flaps are then carried to the level of the thyroid cartilage and the anterior border of the mandible.

The strap muscles are identified and dissected in the midline until the thyroid cartilage is identified. The mandibular symphysis is then identified. A drill is used to bore a hole at the symphysis. A wire can be used to suspend sutures, or they may be placed directly in the hole. Three 3-0 nylon sutures are passed along the superior edge of the thyroid cartilage and periosteum; 1-2 sutures are also placed at the inferior edge of the cartilage. An anterosuperior displacement of the larynx and a widening of the hypopharynx occur as the sutures are tightened. Closure of the neck is in a standard layered fashion.[14]

Complications include wound infection, bleeding, hematoma, and aspiration.

Following surgery, patients should be observed for aspiration; swallow studies can be performed to delineate silent aspiration. In addition, patients should receive wound care and 3 doses of postoperative antibiotics.

Total and Partial Cricoid Resection

Partial cricoid resection is usually performed as an adjunct during reconstruction of the oropharynx after tumor resection. In 1993, Cummings proposed subperichondrial cricoidectomy instead of laryngectomy.[15, 16, 17]

Indications for this procedure include chronic aspiration with poor or no chances of recovery.

Contraindications to total or partial cricoid resection include good prognosis for neurologic recovery or return of swallowing capability.

For a total cricoidectomy, the patient is prepared in a similar fashion to that of a tracheotomy (see Tracheotomy above). A midline neck incision or an apron incision is performed to the level of the strap muscles and the trachea. The tracheostome is performed, as previously described, and the cricoid ring is identified. The cricoid is incised anteriorly and is grasped with skin hooks. The cricoid cartilage is then removed after elevation of the cartilage in the subperichondrial plane. The inner perichondrium is closed, and the mucosa is sutured after infolding the cut ends. The sternohyoid muscle is placed between the proximal and distal stumps, and the outer perichondrium is closed. Neck closure is performed in a layered fashion, as previously described.[15]

Partial cricoidectomy is approached as described above, except only a submucosal segment of the posterior cricoid cartilage is resected and a cricopharyngeal myotomy is performed.

Complications include pharyngotracheal fistula, wound infection, bleeding, hematoma, and pneumothorax.

Postoperative care is similar to that following a tracheotomy (see Tracheotomy above). Adequate wound care must be provided. Sutures are removed in 7-10 days. Antibiotics are administered postoperatively for 3 doses.

Vocal Fold Medialization

This procedure is used in the setting of aspiration secondary to unilateral paralysis or atrophy of the vocal folds. Isshiki popularized the procedure in 1974, and he described an external approach via the thyroid cartilage and the placement of a silastic subperichondrial implant to mobilize the vocal fold (thyroplasty type 1).[18]

This procedure is indicated when vocal cord paralysis or atrophy is the etiology of aspiration secondary to inadequate glottic closure.

Contraindications may include poor pulmonary reserve (ie, chronic obstructive pulmonary disease [COPD]).

The patient is placed in the supine position with the neck extended and is prepared and draped in the usual sterile fashion. During the procedure, the patient is under monitored sedation with local anesthesia. The incision is placed at the level of the thyroid cartilage. The incision is carried through the subcutaneous tissue, and the strap muscles are divided in the midline to the level of the thyroid cartilage.

The anterior lateral surface of the thyroid cartilage is skeletonized on the paralyzed side to the level of the perichondrium, and the height of the cartilage at the notch is measured anteriorly with calipers. Next, the middle is marked, and the lateral portion is elevated at the middle third of the affected side with a perichondrial elevator.

Windows are based 5-6 mm from the middle mark, which approximates the anterior commissure of the glottis. Males require a window of 6 X 12 mm, and females require a window of 4 X 9 mm.[19] The cartilage is marked through the perichondrium (with either a Bovie needle tip or methylene blue at the 4 corners), and a posterior-based flap of perichondrium is raised. The cartilage is then incised with a No. 11 blade (or, if calcified, drilled with a diamond burr) to approximately half the width of the cartilage. The rest is elevated using a Penfield elevator to the inner perichondrium.

The inner perichondrium is not transgressed but is elevated on the inner surface if the window is removed. Alternatively, the perichondrial window may be left in place, thus requiring a smaller silastic implant.[20] The patient's voice is checked at various levels of medialization to determine the size of the implant by depressing the window into the larynx. The silastic implant is formed and tested, with reshaping as needed until the desired result is achieved.

A fiberoptic laryngoscopy is performed to determine closure of the glottic defect. The implant may be sutured in place with permanent sutures or created with a "lip" to prevent migration. The perichondrium is closed with 5-0 absorbable sutures, and a layered closure of the neck wound is performed.[19, 21]

Endoscopic approaches that involve injection of varying substances to stiffen and/or medialize the vocal fold have been described. Teflon injection was once common but is now rarely performed because of the development of Teflon granulomas, extrusion, and migration. Glycerin, collagen, and Gelfoam injections are performed but only have a temporary effect. These injections are commonly used for vocal folds in which function may be expected to return and/or as a prethyroplasty medialization procedure.

Indications include glottic insufficiency and aspiration with unilateral vocal fold paralysis. Contraindications to this procedure are cancer of the larynx and bilateral vocal fold paralysis.

Complications include bleeding, infection, airway obstruction, exercise intolerance, dysphonia,[22] and granuloma formation. The patient must remain hospitalized for 24 hours following surgery for airway observation. Antibiotics are administered postoperatively for 3 doses.

Laryngeal Closures

Habal and Murray described the creation of an epiglottic flap for laryngeal closure in 1972, and, in 1983, they described a supraglottic closure with an epiglottic flap.[1] In 1975, Montgomery described a glottic closure technique that entails a midline thyrotomy with suturing of the true vocal cords, ventricles, and posterior commissure.[23]

Since that time, both endoscopic and external approaches have been described to perform either epiglottic or glottic closure procedures.

The epiglottis can be sutured over the glottis, and/or the vocal cords can be closed with sutures. These procedures require an alternate route of respiration, and a tracheotomy is required. These procedures are reversible, and they should be used in the setting of a reasonable expectation of return of functional laryngeal protection by the vocal folds.

Supraglottic closure with epiglottic flapo Indications include aspiration secondary to glottic incompetence.

Contraindications to this procedure are chronic aspiration with a poor recovery prognosis.

o During the procedure, a lateral pharyngotomy approach is undertaken, and the epiglottis is sutured to the aryepiglottic folds and arytenoids. Careful denuding of these areas at the points of contact is undertaken prior to suturing. The base of the epiglottis may be scored to lessen its elasticity.

o Although dehiscence of the flap may ensue, botulinum toxin injection is reportedly a useful adjunct to limit vocal fold movement in prevention of this complication.[24]

o Following surgery, patients should receive tracheotomy care, postoperative antibiotics, wound care, and, when appropriate, drain removal. Patients should be monitored for dehiscence with recurrent aspiration.

Glottic closureo Indications include aspiration secondary to glottic incompetence.o Contraindications to this procedure are chronic aspiration with a poor

chance of recovery.o During the procedure, a midline thyrotomy is performed, and the true

cords, ventricles, and arytenoids are denuded of epithelium. The larynx is closed with sutures, passing through the thyroid cartilage, the anterior commissure ipsilaterally to the contralateral side through the vocal cord, and the arytenoid cartilage. Sutures then pass back through the posterior portion of the ipsilateral cord and the thyroid cartilage. The other side is similarly addressed, and the thyrotomy is closed in a standard fashion.[23]

o Complications include an inability to reverse secondary to severe glottic scarring (see Tracheotomy above).

o Patients should receive adequate care following surgery, including tracheotomy care, postoperative antibiotics, and wound care.

Tracheoesophageal Diversion

Lindeman originated tracheoesophageal diversion (see History of the Procedure).

This procedure is indicated for patients with severe, life-threatening, chronic aspiration who have a potential for recovery from the disease process that causes aspiration.

Contraindications to tracheoesophageal diversion include upper tracheal pathology.

The most common incision used is an apron type that allows for easy incorporation of the tracheostomy stoma in patients who have had prior tracheostomy placement. The incision starts along the posterior edge of one sternocleidomastoid muscle superior to the stoma, curves down to the stoma and then curves upward on the contralateral side following the edge of the sternocleidomastoid (SCM) muscle. The skin flaps are then elevated in the subplatysmal plane.

When performing laryngectomy for aspiration, a narrow field of resection is performed, and the hyoid, strap musculature, and the hypopharyngeal mucosa are preserved.[10] The larynx is skeletonized after separation of the strap muscles in the midline. The thyroid isthmus is divided and the thyroid is released from the ligamentous attachments to the larynx and the trachea.

The posterior border of the thyroid cartilage is exposed, and the inferior constrictor muscle attachment to the thyroid cartilage is identified. Subsequently, the attachment is released along the ala of the thyroid cartilage. The superior laryngeal nerve with accompanying artery and vein are ligated and divided bilaterally. The superior horn of the thyroid cartilage is identified, and the pyriform sinus mucosa is dissected free of the thyroid cartilage bilaterally. The thyrohyoid membrane is incised along the inferior border of the hyoid, and the larynx is mobilized. The trachea is transected at the level of the previous stoma, and the posterior trachea along with the cricoid cartilage is carefully separated from the esophagus. The anterior wall of the distal tracheal segment is then sutured to the skin with a heavy suture, and an armored tube is placed.

The pharynx is entered via the piriform sinus or the vallecula. Alternatively, the pharynx may be entered at the arytenoids, with a limited infrahyoid pharyngotomy performed. This allows preservation of the pharyngeal mucosa in vallecula, aryepiglottic, and postcricoid areas. However, the classic incision is carried along the walls of the sinuses medially and along the vallecula and epiglottis superiorly. Once the level of the cricoid cartilage is reached, the incisions are joined (ie, superior and inferior incisions), and the larynx is removed. The pharynx is then closed using an inverted running-type Connell stitch with 3-0 Vicryl over a nasogastric tube. The constrictor muscles are sutured in a similar fashion to provide for a second-layer closure.

Suturing the skin edges to the tracheal mucosa without tension forms the permanent tracheostomy. This may require defatting of the adjacent skin and/or subcutaneous tissue. Lastly, the wound is closed in layered fashion with reapproximation of platysmal, subcutaneous, and epidermal layers. If a tracheotomy was originally present in the skin flap, excision of the scarred tissue is required, and the defect is repaired as meticulously as possible. Complications include pharyngocutaneous fistula, infection, stomal stenosis, and subcutaneous hematoma.

For postoperative care, the wound drainage is monitored. Drains are discontinued when minimal drainage is noted. Wounds are covered with topical antibiotic ointment. Sutures are removed in 7-10 days. Care of the tracheostomy is as

previously noted. Prior to resuming oral diet, a swallow study may be performed to exclude subclinical pharyngeal or esophageal leakage. Phonation may be restored postoperatively with minimal aspiration risks by using the Blom-Singer prosthesis via tracheoesophageal puncture.

In 1997, Krespi and Blitzer reported on 10 patients who were treated with this technique after other procedures had failed for aspiration; they noted universal success noted in all 10 patients.[11]

Laryngeal Suspension

Suspension of the supraglottic laryngeal structures may be performed to manage hypopharyngeal collapse. Laryngeal suspension can allow for easier swallowing via a wider hypopharynx

Indications for laryngeal suspension include aspiration associated with hypopharyngeal collapse such as that sometimes seen following supraglottic and/or hypopharyngectomy. Relative contraindications to laryngeal suspension include life-threatening aspiration because the benefit from this technique is modest and indicated for only a narrow spectrum of patients. It is performed most commonly in conjunction with supraglottic laryngectomy and/or hypopharyngectomy.

The anterior neck is prepared and draped in a sterile fashion. A horizontal skin incision at the level of the thyroid cartilage is made followed by elevation of subplatysmal flaps to the level of the thyroid cartilage and the anterior border of the mandible.

The strap muscles are identified and dissected in the midline until the thyroid cartilage is identified. The mandibular symphysis is then identified. A drill is used to bore a hole at the symphysis. A wire can be used to suspend sutures, or they may be placed directly in the hole. Three permanent sutures are passed along the superior edge of the thyroid cartilage and periosteum; 1-2 sutures are also placed at the inferior edge of the cartilage. An anterosuperior displacement of the larynx and a widening of the hypopharynx occur as the sutures are tightened. Closure of the neck is in a standard layered fashion.[14]

Complications include wound infection, bleeding, hematoma, and aspiration.

Following surgery, patients should be observed for aspiration; swallow studies can be performed to delineate silent aspiration. Perioperative antibiotics are commonly used.

Total and Partial Cricoid Resection

Partial cricoid resection is usually performed as method for reconstruction of the stenotic larynx of for tumor excision. In 1993, Cummings proposed subperichondrial cricoidectomy with permanent tracheostomy instead of laryngectomy as a method for managing chronic aspiration.[15]

Indications for this procedure include chronic aspiration with poor or no chances of recovery. Contraindications to total or partial cricoid resection include good prognosis for neurologic recovery or return of swallowing capability.

For a total cricoidectomy, the patient is prepared in a similar fashion to that of a tracheotomy (see Tracheotomy above). A midline neck incision or an apron incision is performed to the level of the strap muscles and the trachea. The tracheostomy is performed, as previously described, and the cricoid ring is identified. The cricoid is incised anteriorly and is grasped with skin hooks. The cricoid cartilage is then

removed after elevation of the cartilage in the subperichondrial plane. The inner perichondrium is closed, and the mucosa is sutured after infolding the cut ends. The sternohyoid muscle is placed between the proximal and distal stumps, and the outer perichondrium is closed. Neck closure is performed in a layered fashion, as previously described.[15]

Partial cricoidectomy is approached as described above, except only a submucosal segment of the posterior cricoid cartilage is resected and a cricopharyngeal myotomy is performed. Complications include pharyngotracheal fistula, wound infection, bleeding, hematoma, and pneumothorax.

Postoperative care is similar to that following a tracheotomy (see Tracheotomy above). Adequate wound care must be provided. Sutures are removed in 7-10 days. Perioperative antibiotics are recommended.

Vocal Fold Medialization

This procedure is most commonly used in the setting of aspiration secondary to unilateral paralysis or atrophy of the vocal folds. Isshiki popularized the procedure in 1974, and he described an external approach via the thyroid cartilage and the placement of a subperichondrial implant to mobilize the vocal fold (thyroplasty type 1).[18] Bilateral vocal fold medialization can be done in a tracheotomized patient and has recently been reported to have excellent success rate in managing chronic aspiration.[25]

Unilateral medialization is indicated when vocal cord paralysis or atrophy is the etiology of aspiration secondary to inadequate glottic closure. Bilateral medialization is an effective option in the management of severe chronic aspiration. It allows for maintenance of a good voice, with a possible return to oral diet, but tracheostomy is required. This procedure is easily reversible if the patient's condition improves. Contraindications may include poor pulmonary reserve (ie, chronic obstructive pulmonary disease [COPD]).

The patient is placed in the supine position with the neck extended and is prepared and draped in the usual sterile fashion. During the procedure for a unilateral medialization, the patient is preferred to be under monitored sedation with local anesthesia in order to better fine tune the implant size. The incision is placed at the level of the thyroid cartilage. The incision is carried through the subcutaneous tissue, and the strap muscles are divided in the midline to the level of the thyroid cartilage.

The anterior lateral surface of the thyroid cartilage is skeletonized to the level of the perichondrium, and the height of the cartilage at the notch is measured anteriorly with calipers. The middle is marked. Windows are based 5-6 mm from the middle mark, which approximates the anterior commissure of the glottis. Males require a window of 6 X 12 mm, and females require a window of 4 X 9 mm.[19]

The cartilage is marked through the perichondrium (with either a Bovie needle tip or methylene blue at the 4 corners), and a posterior-based flap of perichondrium is raised. The cartilage is then incised with a No. 11 blade (or, if calcified, drilled with a diamond burr) to approximately half the width of the cartilage. The rest is elevated using a Penfield elevator to the inner perichondrium.

The inner perichondrium is not transgressed but is elevated on the inner surface if the window is removed. Alternatively, the perichondrial window may be left in place, thus requiring a smaller silastic implant.[20] The patient's voice is checked at various levels of medialization to determine the size of the implant by depressing the window into the larynx. The silastic implant is formed or a premade implant placed and in the

sedated patient tested using fiberoptic laryngoscopy to view the larynx in addition to hearing vocal quality.

Reshaping/resizing can then be done as needed until the desired result is achieved.

The implant may be sutured in place with permanent sutures or created with a "lip" to prevent migration. The perichondrium is closed with 5-0 absorbable sutures, and a layered closure of the neck wound is performed.[19, 21]

Endoscopic approaches that involve injection of varying substances to stiffen and/or medialize the vocal fold have been described. Teflon injection was once common but now is rarely performed because of the development of Teflon granulomas, extrusion, and migration. Glycerin, collagen, and Gelfoam injections are performed but only have a temporary effect. These injections are commonly used for vocal folds in which function may be expected to return and/or as a diagnostic maneuver to predict outcome of a more permanent injection or external thyroplasty medialization procedure. Substances with more permanence include fat and hydroxyapatite.

Indications the unilateral medialization include glottic insufficiency and aspiration with unilateral vocal fold paralysis. In cases of bilateral paralysis/incompetence in a patient with ongoing aspiration complications in spite of tracheostomy, the bilateral procedure can be considered. Contraindications to this procedure include most cases with prior or active cancer of the larynx.

Complications include bleeding, infection, airway obstruction, exercise intolerance, dysphonia,[22] and granuloma formation. In most cases, swallowing studies are repeated before expanding a restricted diet following surgery.

Adjunctive Procedures

Cricopharyngeal myotomy Cricopharyngeal myotomy is performed for achalasia secondary to

sustained contraction of the cricopharyngeus muscle during swallowing. This is usually secondary to neurologic disorders but may be used in swallowing dysfunction after resection of supraglottic, oral, and oropharyngeal carcinoma.

Indications include cricopharyngeal achalasia in conjunction with Zenker diverticulum and oculopharyngeal muscular dystrophy. Contraindications against this as the primary procedure for aspiration include the lack of elevated manometric pressures and life-threatening aspiration.

During the procedure, the patient is positioned, with the neck prepared and draped in the usual sterile fashion. Once the patient reaches an appropriate depth of surgical general endotracheal anesthesia, an esophageal bougie or cuffed endotracheal tube is passed into the cervical esophagus. Then, via a lateral cervical approach to the skin, subcutaneous tissue and platysma are incised along the anterior border of the SCM muscle.

The trachea and the carotid sheath are identified and retracted medially and laterally, respectively. The pharynx is mobilized to reveal the posterior cricopharyngeus muscle. The muscle is incised over the previously inserted tube (if an endotracheal tube was inserted, the cuff is inflated) down to the esophageal mucosa. The neck is closed in the standard fashion with a drain.

Complications to this procedure include salivary fistula, wound infections, recurrent laryngeal nerve injuries, and vocal cord paralysis. Postoperative care includes wound drain observation for increasing drainage once feeding begins, wound care, and antibiotics.

Gastrostomy/jejunostomy Patients who experience chronic aspiration of orally ingested material

may benefit from a feeding gastrostomy or jejunostomy. They may be performed

either as an open procedure or as an endoscopic procedure. These procedures allow for bypass of the upper aerodigestive system and prevent aspiration through avoidance of swallowing. They do not prevent reflux, and positioning during and after feeding is important to prevent aspiration of refluxate.

Aspiration is well documented in the presence of feeding enteral tubes and accounts for a significant degree of morbidity and mortality. In 1992, Jarnigan et al reported 15% aspiration pneumonia and 50% mortality in patients who had undergone percutaneous gastrostomy placement (PEG).[26] In 2000, Klodell et al reported a rate of 4% aspiration pneumonia in traumatically brain-injured patients undergoing PEG feedings.[27]Alimentary bypass procedures are frequently the first interventions in chronic aspiration secondary to swallow dysfunction.

Percutaneous endoscopic gastrostomy This procedure is indicated in patients with dysphagia, chronic

aspiration, and/or malnutrition with functioning gut. Jejunostomy tubes may be placed via the gastrostomy into the jejunum in cases of gastroparesis.

Contraindications include infections of the abdominal wall, nonfunctional gut, bleeding diathesis, unstable neck/cervical spine, intestinal perforation, and unstable cardiac or pulmonary conditions. For surgery, the patient is brought to the endoscopy suite and is placed under conscious sedation or general endotracheal anesthesia. An oral airway large enough for the flexible esophagoscope is inserted in the mouth. The tip of the endoscope is passed to the level of the cricopharyngeus muscle with active swallowing by the sedated patient. The endoscope is then passed to the stomach.

The abdomen is prepared and draped in a sterile fashion. The abdominal operator can see the endoscopic light shining through the abdominal wall. A left upper quadrant abdominal puncture is performed with a Seldinger-type needle technique. A wire is passed via the needle into the stomach and is grasped with a snare by the endoscopist. This wire is brought out via the mouth, and a feeding tube is advanced over it.

The feeding tube is fastened via interior and exterior flanges that hold the tube in place. Feedings may begin on the first postoperative day.[28]

Complications include infection of the stoma, bleeding, peritonitis, esophageal perforation, and obstruction of the tube. Patients should receive perioperative antibiotics and wound care. The caregiver should be provided with instructions on flushing and maintaining patency of the tube.

Fundoplication Gastric reflux that has not responded to medical management and that

is associated with aspiration pneumonia may benefit from fundoplication. In this procedure, a portion of the stomach is wrapped around the lower esophagus to re-create a sphincteric mechanism, thus preventing reflux. Endoscopic and open abdominal approaches are reported in the literature. Nissen described a 360° wrap.[29]

Indications include failure to thrive, refractory reflux, emesis, aspiration pneumonitis/pneumonitis, esophageal stricture, and Barrett esophagus/esophagitis despite conservative/medical therapy. Contraindications to this procedure are an inadequate trial of medical therapy and aspiration secondary to causes other than reflux (eg, glottic incompetence, neurologic swallowing dysfunction).

During the procedure, the patient is placed in a supine position, and the abdomen is prepared and draped in a sterile fashion. A standard incision is performed, and the incision is carried through the skin, subcutaneous tissue, muscle layers, and peritoneum. The gastric fundus is identified. The vagus nerves are identified and preserved.

The gastric wrap is performed with 3 cm of the fundus encircling the intra-abdominal portion of the esophagus. Proper placement of heavy silk sutures to

the seromuscular layers of the stomach, the anterior esophageal wall smooth muscle layer, and the fundus is critical to this procedure. The short gastric vessels must be identified; they can be a significant source of bleeding. These vessels may be ligated as needed to achieve a tensionless wrap. Once the wrap is in place, the wound is closed in a layered fashion.[30]

Complications inherent to this procedure include early satiety, esophageal obstruction, small bowel obstruction, wound infection, dehiscence, pancreatitis, inadvertent splenectomy, inability to belch, wound breakdown, and failure to control gastroesophageal reflux.

Postoperative care includes wound care and antibiotics. A nasogastric tube is used for drainage. When patients resume a solid diet, small, well-chewed food boluses are recommended.

Control of salivary output Aspiration of salivary secretions can be a source of aspirated material.

Control of salivary output has been attempted via several surgical procedures: excision of salivary glands, ductal ligation, ductal re-routing, parasympathetic nerve resection, and more recently, reduction of salivary flow has been obtained successfully by injection to the submandibular and parotid glands with botulinum toxin.[31, 32]

Ductal rerouting is not commonly used for aspiration. Increased posterior secretions in a patient who is aspirating may actually worsen both the severity and the frequency of aspiration. Salivary glands produce 1500 mL of saliva per day.[33] Bilateral 4-duct ligation or bilateral submandibular gland excision and parotid duct ligation eliminates most oropharyngeal secretions that lead to aspiration. Four-duct ligation is advocated as an easier and shorter procedure with equal effectiveness. Excision of the submandibular glands is advocated to minimize the possibility of increased risk of abscess formation in retained submandibular glands. Some controversy exists as to the degree of success in reducing the frequency of lower respiratory tract infections/complications of aspiration by control of salivary flow with either 4-duct ligation or bilateral submandibular gland excision.[34, 35]

Bilateral submandibular gland excision and parotid duct ligation This procedure is indicated in patients with chronic aspiration of

oropharyngeal secretions most commonly associated with cerebral palsy, epilepsy, and Down syndrome and other neuromuscular disorders. Absolute contraindications are not noted.

For surgery, the patient is placed on the operating table in the supine position, with a shoulder role. The submandibular incisions are drawn parallel and 2 finger breadths below the mandible. Paralytic agents are avoided to assist with ability to monitor marginal branch of the facial nerve.

An incision is made to the subplatysmal plane. The inferior aspect of the submandibular gland is identified and the superficial fascia over the gland is incised horizontally. In this subfacial plane, the dissection is carried superiorly, which will allow protection for the marginal branch of the facial nerve, which passes deep to the platysma and superficial to the fascia of the submandibular gland. The posterior facial vein is usually clamped and ligated and the superior end retracted, which further protects the nerve.

The anterior facial artery and vein are identified, and sometimes need to be divided. The dissection is then carried medial to the posterior facial vein and anterior to the anterior belly of the digastric muscle. The mylohyoid muscle is identified, and the attachments to the submandibular gland are dissected away from the gland.

The free edge of the mylohyoid is retracted, and the lingual nerve is identified. Dissection using a blunt dissector below the lingual nerve identifies the hypoglossal nerve and the Wharton duct. The parasympathetic ganglion is

identified along the lingual nerve, and fibers to the gland at the submandibular ganglion are divided. The duct is divided and ligated close to the floor of the mouth. All further attachments are released from the gland. The opposite side is done in a similar fashion and the neck wounds are closed in layers, as previously described.[36]

Parotid duct ligation is then undertaken. The mouth is opened with a Jennings or dental gag. The opening of the parotid duct is identified opposite the maxillary second molar. The duct is probed with nasolacrimal probes and the area infiltrated with local anesthetic with epinephrine. An elliptical incision is made around the duct, which is then dissected out for approximately 1cm, ligated, and divided. The stump is buried and the wound is closed with chromic suture.[30] The opposite side is addressed in a similar fashion.

Ensuing complications include marginal mandibular nerve injuries with resultant lower lip paralysis, wound infection, lingual and hypoglossal nerve injuries, and salivary fistulas. Chronic parotitis and/or submandibular sialadenitis may occur with duct ligation procedures.

Postoperative care includes wound care and perioperative antibiotics are usually used. Drains are often used and removed once drainage is minimal.

Ligation of bilateral submandibular ducts and bilateral parotid ducts This procedure is indicated in patients with chronic aspiration of

oropharyngeal secretions most commonly associated with cerebral palsy, epilepsy, and Down syndrome and other neuromuscular disorders.

Absolute contraindications are not noted. For surgery, the surgeon is at the head of the bed with the patient

supine and a roll under the shoulders. Dental blocks can be used to open the mouth. Local anesthesia is injected into the floor of the mouth around the submandibular duct punta and around each parotid duct orifice. Midway between the submandibular puncta and plica sublingularis, the mucosa is incised and approximately 0.5 cm of the submandibular duct skeletonized, clips or suture ligatures applied, and the mucosa closed. The parotid ducts are then ligated in a manner as noted in the paragraphs above.

If eating by mouth, patients are usually able to resume their preoperative diet within hours of the procedure. Antibiotics are not routinely used. Possible complications include suppurative sialadenitis, recannulation of the ducts, and dry mouth.

Botulinum toxin injection to submandibular and parotid glands Local injection of botulinum toxin type A acts at the cholinergic

receptors within the salivary glands to reduce the salivary secretions. The effect is temporary, usually lasting approximately 12 weeks. The procedure is usually done with ultrasound guidance to ensure that the injection is into the substance of the glands. The amount injected is approximately 20 units to each parotid gland (divided into 3 locations in the gland) and 10-20 units into each submandibular gland (divided into 2 locations in each gland). Potential complications include extravasation outside the gland tissue leading to facial paresis, airway, or swallowing dysfunction. The incidence is low and complications, like the beneficial aspects of this treatment, are transient.[31, 32]

Preoperative DetailsSee Surgical therapy.

Intraoperative DetailsSee Surgical therapy.

Postoperative DetailsSee Surgical therapy.

Follow-upSee Surgical therapy.

ComplicationsComplications to surgical intervention for chronic aspiration are procedure specific and are outlined with each procedure.

Outcome and PrognosisOutcome and prognosis to surgical intervention for chronic aspiration are procedure specific and are included with each procedure.

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pneumonia. Use of an epiglottic flap to the arytenoids. Plast Reconstr Surg. Mar 1972;49(3):305-11. [Medline].

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5. Schonhofer B, Barchfeld T, Haidl P, Kohler D. Scintigraphy for evaluating early aspiration after oral feeding in patients receiving prolonged ventilation via tracheostomy. Intensive Care Med. Mar 1999;25(3):311-4.[Medline].

6. Strome M, Shapiro J. Aspiration. In: Fried MP, ed. The Larynx: A Multidisciplinary Approach. 2nd ed. St Louis: Mosby-Year Book; 1996:358.

7. Chas M, Steinberg, Byron J, Bailey. Surgery of the Larynx. WB Saunders and Co; 1985:322.

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9. Simonelli M, Ruoppolo G, de Vincentiis M, Di Mario M, Calcagno P, Vitiello C, et al. Swallowing ability and chronic aspiration after supracricoid partial laryngectomy. Otolaryngol Head Neck Surg. Jun 2010;142(6):873-8. [Medline].

10. Wisdom G, Krespi YP, Blitzer A. Surgical therapy for chronic aspiration. Operative Techniques in Otolaryngology-Head and Neck Surgery. 1997;Dec:199-208.

11. Krespi YP, Blitzer A. Laryngectomy for aspiration: Narrow field technique. Operative Techniques in Otolaryngology-Head and Neck Surgery. 1997;Dec:227-30.

12. Li SQ, Chen JL, Fu HB, Xu J, Chen LH. Airway management in pediatric patients undergoing suspension laryngoscopic surgery for severe laryngeal obstruction caused by papillomatosis. Paediatr Anaesth. Dec 2010;20(12):1084-91. [Medline].

13. Lee DH, Park SJ. Effects of 10% lidocaine spray on arterial pressure increase due to suspension laryngoscopy and cough during extubation. Korean J Anesthesiol. Jun 2011;60(6):422-7. [Medline]. [Full Text].

14. Lore JM. An Atlas of Head and Neck Surgery. 3rd ed. Philadelphia: WB Saunders; 1988:920.

15. Cummings CW. Otolaryngology-Head and Neck Surgery. 2nd ed. St Louis: Mosby; 1993:2065.

16. Czecior E, Scierski W, Misiolek M, Sowa P, Namyslowski G. Reconstruction of the larynx after a resection of a huge chondrosarcoma. Otolaryngol Pol. Nov-Dec 2011;65(6):459-61. [Medline].

17. Houlton JJ, de Alarcon A, Johnson K, Meinzen-Derr J, Brehm SB, Weinrich B, et al. Voice outcomes following adult cricotracheal resection. Laryngoscope. Sep 2011;121(9):1910-4. [Medline].

18. Isshiki N, Morita H, Okamura H, Hiramoto M. Thyroplasty as a new phonosurgical technique. Acta Otolaryngol. Nov-Dec 1974;78(5-6):451-7. [Medline].

19. Stasney CR. Thyroplasty: Type one. In: Bailey B, et al, eds. Atlas of Head and Neck Surgery/Otolaryngology. Philadelphia: Lippincott; 1996:594.

20. Myers, Eugene N, et al. Operative Otolaryngology-Head and Neck Surgery. Philadelphia: WB Saunders; 1997.

21. Koufman JA. Management of the paralyzed vocal cord. In: Myers E, et al, eds. Operative Otolaryngology-Head and Neck Surgery. Philadelphia: WB Saunders; 1997:380-395.

22. Beaty MM, Hoffman HT. Impact of laryngeal paralysis and its treatment on the glottic aperture and upper airway flow characteristics during exercise. Otolaryngol Head Neck Surg. Jun 1999;120(6):819-23.[Medline].

23. Montgomery WW. Surgery to prevent aspiration. Arch Otolaryngol. Nov 1975;101(11):679-82. [Medline].

24. Pototschnig CA, Schneider I, Eckel HE, Thumfart WF. Repeatedly successful closure of the larynx for the treatment of chronic aspiration with the use of botulinum toxin A. Ann Otol Rhinol Laryngol. Jul 1996;105(7):521-4. [Medline].

25. Thevasagayam MS, Willson K, Jennings C, Pracy P. Bilateral medialization thyroplasty: an effective approach to severe, chronic aspiration. J Laryngol Otol. Aug 2006;120(8):698-701. [Medline].

26. Jarnagin WR, Duh QY, Mulvihill SJ, Ridge JA, Schrock TR, Way LW. The efficacy and limitations of percutaneous endoscopic gastrostomy. Arch Surg. Mar 1992;127(3):261-4. [Medline].

27. Klodell CT, Carroll M, Carrillo EH, Spain DA. Routine intragastric feeding following traumatic brain injury is safe and well tolerated. Am J Surg. Mar 2000;179(3):168-71. [Medline].

28. Kimmey MB, Silverstein FE. Gastrointestinal endoscopy. In: Harrison's Principles of Internal Medicine. 13th ed. McGraw-Hill, Inc; 1994:1350-1354.

29. Grosfeld JL. Pediatric surgery. In: Sabiston, ed. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 14th ed. Philadelphia: WB Saunders; 1991:1167.

30. Dundas DF, Peterson RA. Surgical treatment of drooling by bilateral parotid duct ligation and submandibular gland resection. Plast Reconstr Surg. Jul 1979;64(1):47-51. [Medline].

31. Ellies M, Gottstein U, Rohrbach-Volland S, Arglebe C, Laskawi R. Reduction of salivary flow with botulinum toxin: extended report on 33 patients with drooling, salivary fistulas, and sialadenitis. Laryngoscope. Oct 2004;114(10):1856-60. [Medline].

32. Raval TH, Elliott CA. Botulinum Toxin Injection to the Salivary Glands for the Treatment of Sialorrhea With Chronic Aspiration. Annals of Otology, Rhinology & Laryngology. 117(2):118-122.

33. Lee KJ. Essential Otolaryngology: Head & Neck Surgery. Appleton & Lange; 1999:459.

34. Vijayasekaran S, Unal F, Schraff SA, Johnson RF, Rutter MJ. Salivary gland surgery for chronic pulmonary aspiration in children. Int J Pediatr Otorhinolaryngol. Jan 2007;71(1):119-23. [Medline].

35. Gerber ME, Gaugler MD, Myer CM 3rd, Cotton RT. Chronic aspiration in children. When are bilateral submandibular gland excision and parotid duct ligation indicated?. Arch Otolaryngol Head Neck Surg. Dec 1996;122(12):1368-71. [Medline].

36. Olsen KD. Submandibular salivary gland excision. In: Bailey B, et al, eds. Atlas of Head and Neck Surgery/Otolaryngology. Lippincott; 1996:12-13.

37. El-Hakim H, Richards S, Thevasagayam MS. Major salivary duct clipping for control problems in developmentally challenged children. Arch Otolaryngol Head Neck Surg. May 2008;134(5):470-4. [Medline].

38. El-Hakim H, Richards S, Thevasagayam MS. Major salivary duct clipping for control problems in developmentally challenged children. Arch Otolaryngol Head Neck Surg. May 2008;134(5):470-4. [Medline].

39. Hricko P, Storck C, Schmid S, Stoeckli SJ. Partial cricotracheal resection for successful reversal of laryngotracheal separation in patients with chronic aspiration. Laryngoscope. May 2006;116(5):786-90.[Medline].

40. Raval TH, Elliott CA. Botulinum toxin injection to the salivary glands for the treatment of sialorrhea with chronic aspiration. Ann Otol Rhinol Laryngol. Feb 2008;117(2):118-22. [Medline].

41. Snyderman CH, Johnson JT. Laryngotracheal separation for intractable aspiration. Ann Otol Rhinol Laryngol. Sep-Oct 1988;97(5 Pt 1):466-70. [Medline].

42. Snyderman CH, Johnson JT, Eibling DE. Laryngotracheal diversion and separation in the treatment of massive aspiration. Curr Opin Otolaryngol Head Neck Surg. 1994;2:63-67.

43. Thevasagayam MS, Willson K, Jennings C, Pracy P. Bilateral medialization thyroplasty: an effective approach to severe, chronic aspiration. J Laryngol Otol. Aug 2006;120(8):698-701. [Medline].

44. Tucker HM. Management of the patient with an incompetent larynx. Am J Otolaryngol. Fall 1979;1(1):47-56. [Medline].

45. Yarington CT, Sutton D. Clinical experience with the tracheoesophageal anastomosis for intractable aspiration. Ann Otol Rhinol Laryngol. Sep-Oct 1976;85(5 Pt.1):609-12. [Medline].

Laryngotracheal Separation   with Tracheo Tracheal Puncture Case Example

1. DEFINITIONSa. Tracheoesophageal diversion: trachea divided with the lower open segment

sutured to skin (tracheostome) and upper open segment sutured to esophagus (via esophagotomy)

b. Laryngotracheal separation: trachea divided with lower open segment sutured to skin (tracheostome) and upper segment closed on itself (blind pouch)

2. GENERAL CONSIDERATIONSa.

i. Intractable aspiration (see Management of Swallowing Disorders) ii. Desires to proceed by a well-informed patient (and family, support group,

power of attourney)1. "Therapeutic strategies to prevent aspiration are usually

determined by the families, since the patients are often suffering from stroke, brain damage, and intellectual disabilities." (ref Teramoto 2000)

2.  QOL study following laryngectomy (6 pts) and laryngotracheal separation (1 pt) for intractable aspiration (ref Takano 1999)

a. Surgical treatment improves the depression and mood of patient and family

b. Surgical treatment improves feeding status and clincal outlook

iii. Discuss alternative to surgery: NPO (PEG), aggressive pulmonary toilet, treatment of recurrent lung infections, consider prophylactic antibiotics

iv. Ensure conservative measures have been appropriately applied and found to be ineffective 

v. Surgical Options1. Tracheotomy alone (temporarily may help pulmonary toilet;

may worsen chronic aspiration     hence, may be done with: a. Obturation of larynx (placement of Montgomery solid

stent) - greater ease of reversal, problems with leakage about the stent, inducing scarring in the larynx

b. Glottic closure - considered unreliable in presence of mobile vocal cords

c. Supraglottic Closure - efficacy questioned2. Near field laryngectomy - considered by some a procedure of

choice3. Laryngo tracheal separation or tracheoesophageal diversion  -

potentially (very rarely due to underlying conditions) reversiblea. See discussion of relative merits of each belowb. Current philosophy at U of Iowa: favor laryngeotracheal

separation 3. Speech pathology swallowing evaluation

a. OPMSb. FEESc. FEESTd. Bedside swallow 

4. Speech pathology counselling "life w/o the larynx" (see Laryngectomy counselling )5. Medical clearance6. Consent for Surgery

a. Describe indicationsi. "Need to protect lungs from soiling by aspiration of secretions"

b. Describe procedure:i. General anesthesia - neck incision, separate trachea from larynx, suture

trachea to skin as a permanent breathing openinng, close off bottom of larynx (blind pouch)

ii. May consider concurrent 'tracheo-tracheal puncture'c. Describe alternatives:

i. Manage recurrent pneumonias medicallyii. Tracheotomy with obturation of larynxiii. Near field laryngectomy

d. Risks: bleeding, infection, reaction to anesthetice. Potential complication

i. Damage to nerves: lip (marginal mandibular), tongue (hypoglossal, lingual), shoulder (spinal accessory), larynx (vagus/RLN), diaphragm (phrenic)

ii. Leak of salivary (blind pouch, adjacent pharynx)iii. Mediastinitisiv. Narrowing of stoma (stenosis may require secondary opening, use of

long term stent)

NURSING CONSIDERATIONS# Patient head of bed elevated, rotate 180 degress away from anesthesia

1.  (Room Setup)a. Sub-Con

i. Sub-sub-con2. Consideration 2 (Instrumentation and Equipment)

a. Sub Con3. Consideration 3 (Medications (specific to nursing))

a. Sub Con4. Consideration 4 (Prep and Drape)

a. Sub Con5. Consideration 5 (Drains and Dressings)

a. Sub Con6. Consideration 6 (Special Considerations)

a. Sub Con ANESTHESIA CONSIDERATIONS

b. General anesthesia - oro-endotracheali. Sub-sub-con

7. Consideration 2a. Sub Conb.  

OPERATIVE PROCEDURE: LARYNGEAL DIVERSION PROCEDURE# Microdirect laryngoscopy (assess anatomy, arytenoid mobility)

1. Esophagoscopya. To GE junction - possible biopsy (if signs of Barretts, reflux)b. Place Mahoney esophageal dilator for use during procedure to palpate

esophagus2. Injection 1% lidocaine with 1:100,000 epinephrine to

a. stoma site (3 cm circular incision)b. access for separation (9 cm incision at level of cricoid) (ensure adequate skin

bridge between to openings)3. Prep and drape (from lower lip to mid sternum, from shoulder to shoulder)4. Elevate subplatysmal flaps superiorly and inferiorly5. Separate strap muscles and thyroid isthmus (consider thyroid isthmusectomy)

6. Bluntly mobilize trachea (finger dissection, blunt hemostat) to upper mediastinum - avoid injury to RLN's

7. Incise between 3rd and 4th tracheal ring trending superiorly (permit stoma to be bevelled) (depending on the length of the neck the incision may be made higher (between 2nd and 3rd ring) or lower.

8. Separate the posterior tracheal wall from esophagus carefully identifying the grey line (palpation of previously placed Mahoney may be helpful)

9. Create the tracheostomy by suturing the trachea cirumferentially to the lower circular incision

a. Small anesthetic tube placed through skin incision re-routing gas administration from trans oral to the stoma

b. (3-0 vicryl deep, 4-0 chromic running 4 separate quadrants)10. Use Senn retractor within the proximal tracheal stump to retract the stump into the wound

a. Separate the posterior tracheal wall from esophagus superiorlyb. A small entry from into the esophagus may be established to provide a controlled

port of exit of secretions from the otherwise blind pouchc. Alternatively, a blind pouch may be created without and inferior point of egress -

closure the tracheal on itself to create a blind pouch - relaxing incisions may be necessary -

i. (ref Snyderman 1988)1. Incise between 2nd and 3rd ring, do not violate esophagus,

create blind pouch by removing 2nd tracheal ring - invert the underlying subglottic mucosa with interrupted 4-0 vicryl and oversewn with running 3-0 vicryl

2. "concern about pooling of secretiosn and food in the subglottic blind pouch do not appear to be warranted" (emptying of the pouch with the patient supine)

ii.  (ref Eisele 1988)1. Tracheoesophageal diversion: trachea divided between 4th and

5th tracheal rings with proximal tracheal segment anastomosed in end-to side fashion to anterior esophagotomy. 

2. High tracheotomy precludes establishment of a tension-free tracheoesophageal anastomosis, therefore perform Laryngotracheal separation with blind pouch in patients with previous high tracheotomy.

3. Tracheoesophageal diversion favored by these investigators toa. Avoid pooing in the subglottic tracheal pouchb. Permit easier tracheal reconstruction due to longer

tracheal segment11. Tack the anterior wall of the blind pouch to the posterior wall of the trachea (site of

proposed TEP = 1.3 cm below muco-cutaneous edge of the tracheostome)12. To prevent the laryngeal remnant from pulling away from the tracheostome, consider

placement of 3-0 or 4-0 prolene sutures through the cricoid and tied over rub-shods externally (over skin)

OPERATIVE PROCEDURE: TRACHEO-TRACHEAL PUNCTURE  Concurrent placement of a tracheo-tracheal puncture can be done at the time of diversion

1. In the course of step (11) above, orient the anterior wall of the proximal trachea (blind pouch) to coapt the posterior wall of the tracheostome

2. Create and opening communitated from the tracheostome (1.3 cm below the muco-cutaneous edge) to the blind pouch and place a red rubber catheter through the fistula into the pouch exiting the pouch through the small communication into the esophagus.

3. delay placement of TEP prosthesis until wounds healed. POSTOPERATIVE CARE

4. Consideration 1a. Sub-Con

i. Sub-sub-con5. Consideration 2

a. Sub Con CPT CODING

6. 318997. 31611

SUGGESTED READING 

1.a. Eisele DW, Yarington CT, and Lindeman RC: Indications for the

Tracheoesophageal Diversion Procdedure and the Laryngotracheal Separation Procedure  Ann Otol Rhinol Laryngol 97:1988 pp 471-475

b. Lombard LE and Carrau RL: Tracheo-tracheal Puncutre for Voice Rehabilitation After Laryngotracheal Separation. Am J Otolaryngol 2001;22:176-78

c. Snyderman CH and Johnson JT: Laryngotracheal Separation for Intractable Aspiration Ann Otol Rhinol Laryngol 97:1988 pp 466-470

d. Lindeman RC> Diverting the paralyzed larynx: a reviersible procedure for intractable aspiration. Laryngoscope 1975;85:157-80

e. Weisberger EC, Huebsch SA. Endoscopic treatment of aspiration using a laryngeal stent. Otolaryngol Head Neck Surg 1982;90:215-22

f. Hricko P, Storck C, Schmid S, Stoeckli SJ: Partial cricotracheal resection for successful reversal of laryngotracheal separation in patients with chronic aspiration. Laryngoscope 206 May; 116(5):786-90

g. Takano Y, Suga M, Sakamoto O, Sato K, Samejima Y and Ando M: Satisfaction of Patients Treated Surgically for Intractable Aspiration Chest 1999;116:1251-1256

h. Teramoto S, Kon K, and Isasaki Y: Morale and Depression in Patients Treated Srugcially for Intractable Aspiration. Chest 2000;118;564-65

i. Eliachar I, Roberts JK, Hayes JD, and Tucker HM: A vented larygneal stent with phonatory and pressure relief capability. Laryngoscope 97:1264-1269, 1987 

Ann Otol Rhinol Laryngol. 1988 Sep-Oct;97(5 Pt 1):466-70.

Laryngotracheal separation for intractable aspiration.Snyderman CH, Johnson JT.

Source

Department of Otolaryngology, University of Pittsburgh School of Medicine, PA.

AbstractIntractable aspiration may be a life-threatening problem for patients with altered laryngeal function secondary to neurologic disorders or abnormal laryngeal anatomy. Multiple surgical procedures

have been devised to deal with this problem. An effective technique involves the creation of a tracheostoma and closure of the larynx at the first or second tracheal ring. Laryngotracheal separation is relatively easy to perform and potentially reversible. Experience with this technique in six patients who required laryngeal separation for intractable aspiration is described. The procedure was successful in preventing aspiration and recurrent pneumonia associated with neurologic dysfunction, unresectable neoplasm, and conservation laryngeal surgery. One patient of one has had a successful reconstruction.