Surgical Management of Aspiration

1
Surgical Management of Aspiration

• Robert J. Stachler, M.D.
• Associate Professor
• Dept. of Otolaryngology, Head and Neck Surgery
• Wayne State University
• Detroit, MI

2
Outline

• symptoms
• evaluation
• nonsurgical management
• surgical management

3
Introduction

• 3 main functions of larynx
• respiration
• phonation
• airway protection
• aspiration laryngeal penetration of any
  substance below the vocal folds
• - occurs normally 50 of healthy people during
  sleep (Huxley et al., 1978)

4
Introduction

• aspiration is tolerated if
• nl tracheobronchial clearance
• nl defense mechanisms
• bronchopulmonary complications
• volume
• character of aspirate (pH, bacterial)
• bronchospasm, tracheitis, bronchitis, pneumonia,
  pulmonary abscess, sepsis, death

5
At Risk Patients

• impaired swallowing or airway protection
• temp. neurologic dysfunction
• drugs, Etoh, metabolic derangement
• Sz, or infection
• age elderly gt risk
• physiologic, neurologic changes (Aviv et al.,
  1994 Blitzer, 1990)

6
At Risk Patients

• Denture patients
• impaired sensation
• impaired oral control
• Chronic aspiration
• repeated episodes
• requires rapid recognition effective management
  to prevent complications

7
Etiology

• loss of laryngeal protective reflex
• impaired motor activity
• diminished sensation
• Causes long list CVA most common
• degenerative neurologic Dz
• diffuse neurologic dysfx
• head injury, anoxic brain injury, infection, drug
  toxicity

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table 1
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Etiology

• Causes (cont)
• pediatric CP, anoxic encephalopathy, congenital
  or acquired disorders, sequelae from neurotrauma
  or surgery, TE fistula

10
Symptoms

• coughing or choking during swallowing
• silent aspiration no symptoms
• fever
• productive cough with purulent sputum
• weight loss
• dysphagia
• odynophagia

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Evaluation

• H P
• medical Hx, prior surgery or injury
• multidisciplinary
• SLP, neurology, internal medicine, rehab.
  medicine, radiology, GI, thoracic surgery,
  psychiatry
• Exam head neck with CN eval.
• larynx pharynx

12
Evaluation

• Exam (cont)
• esophagoscopy if indicated
• PFTs pulmonary fx reserve
• Radiology
• CXR, MBS with esophagram (VFS)
• (Donner, Silbiger, 1966 Splaingard et al.,
  1988)
• small amt. of barium if at risk (Logemann, 1986)

13
Evaluation

• - different consistencies (with SLP)
• reduce aspiration
• treatment plan (dx and therapy)
• Scintigraphy (Muz et al., 1987, Stachler et al.,
  1996)
• CT or MRI
• fix correctable causes (CP spasm, Zenkers,
  obstructions)

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Nonsurgical Treatment

• antibiotics
• aggressive pulmonary therapy
• NPO, alternative route of nutrition
• NG tubes, cervical esophagotomy, piriform
  sinusotomy, gastrostomy, jejunostomy
• NG tubes
• Does not eliminate risk of aspiration (Ciocon JO
  et al., 1988)
• may increase aspiration (Alessi, Berci., 1986
  Elpern et al., 1987)

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G Tubes

• does not decrease aspiration in neurologically
  impaired patients
• (Hassett et al., 1988 Kadakia et al., 1992)
• Not indicated if GI tract not fx.
• hyperalimentation (eg severe anoxic brain
  injury)

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Special Nursing Care

• positioning
• elevation of the HOB if reflux
• ? difference with endotracheal tube
• (Elpern et al., 1987)
• frequent suctioning of the oral cavity
  oropharynx

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Tracheotomy

• provides airway control
• pulmonary toilet
• reduces dead space
• cuffed tubes do not prevent aspiration (Bone et
  al., 1974 Cameron et al., 1973)
• impairs laryngeal elevation and effective cough
  (Bonanno, 1971)

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Tracheotomy

• physiologic obstruction with cuffed tube
• (Feldman et al., 1966 Nash, 1988)
• TE fistula with indwelling NG tube
• decreased pharyngeal pressures (Blitzer., 1987
  Eibling Gross., 1996)
• Passey-Muir speaking valve
• reduces aspiration (Dettlebach MA, 1995 Stachler
  et al., 1996)

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Tracheotomy

• bypass of upper airway impairs reflex laryngeal
  closure (Sasaki CT et al., 1977 Shaker R., 1995)
• low pressure/ high compliance cuffs minimize
  cuff leak
• do not prevent aspiration (Bernhard WN et al.,
  1979 Pavlin et al., 1975 Petring et al., 1986)

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Vocal Cord Medialization

• vocal fold paralysis esp. sensory deficit
• high vagal lesion
• endoscopic, transcervical approach
• medializes cords
• prevents aspiration (Lewy, 1964 McCaffrey,
  Lipton., 1989 Rontal, 1976)
• medialization laryngoplasty reversible

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Surgery

• chronic aspiration
• continued soilage
• surgical separation may be necessary
• reasonable survival
• duration of survival
• medical status
• mental status
• severity of illness
• quality of life

22
Sacrifices

• normal phonation laryngeal respiration vs.
  airway protection
• patient, family caregiver discussions

23
Ideal Surgical Candidate

• effective in preventing aspiration
• simply achieved
• few complications
• low morbidity
• local anesthesia, if possible, for debilitated
  pts.
• allows phonation and deglutition
• reversible if the underlying condition improves

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Surgical Management
25
Laryngectomy

• narrow-field preserves hyoid, straps, mucosa,
  reduces complications (Briant TDR., 1975)
• practical due to
• low chance of
• recovery of most
• local anesthesia
• TE puncture
• irreversible

26
Subperichondrial Cricoidectomy

• definitive surgical separation of upper resp.
  digestive tract (Eisele et al., 1995)
• outer inner perichondriums elevated
• anterior cricoid removed, lamina preserved
• inner perichon./subglottic mucosa divided,
  inverted, closed subglottic pouch
• straps buttress closure
• tracheostomy necessary

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Subperichondrial Cricoidectomy
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Subperichondrial Cricoidectomy

• Advantages high success rate
• simplicity
• low morbidity
• local anesthesia
• Disadvantages fistula into upper trachea
• tracheostomy needed
• reversibility difficult

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Partial Cricoidectomy

• subtotal submucosal cricoid resection after
  surgery for pharyngeal / BOT tumors
• posterior cricoid lamina removed without
  violating mucosa (Krespi, Pelzer, Sisson, 1985)
• cricopharyngeal myotomy
• trach
• enlarges pharynx, narrows laryngeal inlet
• reduces aspiration, preserves voice

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Endolaryngeal Stents

• Weisberger Huebsch 1982
• endoscopic, suture transcervically
• tracheostomy
• oral intake 3/7
• mortality, tube occlusion
• attempted removal with
• replacement 2/7

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Eliachar Stent

• vented
• aspiration control (11/12), (1990)
• larger stent in 1 failure
• used up to 9 mos
• granulation tissue,
• subglottic web / 3 removals

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Stents

• Advantages easy introduced, prevent aspiration
• Disadvantages lack of uniform success (leakage,
  extrusion), endolaryngeal injury, trach
  displacement with stent occluding trach, patient
  discomfort, need for multiple stents of different
  sizes.

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Epiglottic Flap Closure

• Habal Murray (1972)
• infrahyoid pharyngotomy trach
• epiglottis, AE folds, arytenoids denuded
• Strome Fried modifications (1983)
• decrease tensile strength morselization, linear
  striations, wedge excision
• sever hyoepiglottic thryoepiglottic ligaments
• - decreases dehiscence posteriorly

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Epiglottic Flap Closure Modifications

• posterior inlet left open for phonation (Brooks,
  McKelvie, 1983 Vecchione et al., 1975)
• mandibular suspension of larynx
• increases protection (Warrick-Brown et al., 1986)
• false vocal fold approx. (Cummings et al., 1984)
• success only 50, failures can be revised
• reports of reversal with endoscopy (Stome
  Fried, 1983)

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Epiglottic Flap Closure
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Epiglottic Flap Closure

• Advantages reversibility
• deglutition
• speech preservation if post. glottis open
• TVCs not injured
• Disadvantages high rate of dehiscence
• transcervical approach tracheotomy
• subglottic stenosis risk if reversal (Vecchione
  et al., 1975)

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Vertical Laryngoplasty

• Biller, Lawson, Baek (1983), after glossectomy
• epiglottis, supraglottic larynx 2 layers
• tube with small opening superiorly
• allows deglutition speech
• scoring of cartilage modification to decrease
  dehiscence rate (Meiteles et al., 1993)

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Vertical Laryngoplasty
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Glottic Closure

• Montgomery (1975)
• larynx closed at TVC FVC layers
• midline thyrotomy, surfaces denuded
• nonabsorbable monofilament glottic surfaces
• absorbable suture FVC margins
• trach necessary
• sternohyoid muscle flap (Sasaki et al., 1980,
  1984)

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Glottic Closure

• a removal of glottic mucosa/ transglottic
  sutures
• b FVCs approx.
• c glottis closed

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Glottic Closure

• Results 95 success, one successful reversal
• Advantages good success, deglutition, potential
  reversibility
• Disadvantages transcervical, thyrotomy, loss of
  phonation, trach, endolaryngeal injury,
  challenging procedure
• Contraindication preexisting laryngeal abn.

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Tracheoesophageal Diversion

• Lindemann (1975)
• objectives reliable technique for aspiration,
• preserve larynx RLNs
• reversible potentially
• division of trachea at 4th 5th rings
• proximal segment end to side anastomosis to
  anterior esophagus
• distal segment tracheostoma

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Tracheoesophageal Diversion
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Laryngotracheal Separation

• described in 1976
• pts with high trach
• trachea divide at 2nd
• 3rd rings
• proximal edge sutured
• tracheal closure
• sternothyroid buttress
• distal end stoma

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Modified TE Diversion

• ant. tracheal flap inferior
• half of cricoid ant. 1st
• 2nd tracheal rings removed
• end to end anastomosis
• to ant. esophagus

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Results

• most tolerate nl diet depending on neurologic fx
• reversal with nl voice, swallowing, respiration
  reported (Eisele et al., 1989, 1991 Synderman,
  Johnson, 1988)
• local anesthesia

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TE Diversion

• Indications chronic aspiration without high
  tracheostomy
• allows penetrated secretions to pass to esophagus
• separation technically easier
• complications fistula local care with abx.
• higher rate with prior trach

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TE Diversion

• Reversal neurologic improvement
• VFSS, laryngoscopy
• post CVA, benign tumor resection (Eisele et al.,
  1989)
• Advantages dependable, oral alimentation,
  reversible, children
• Disadvantages transcervical, loss of air powered
  speech, (BS prosthesis manual dexterity, visual
  acuity)

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Questions?

• Thank You!

50
Questions?

• Thank You!