Management of

Intractable Aspiration
Source : Bailey Head-neck surgeryOtolaryngology

 Aspiration pneumonia represents a

major comorbidity in wide variety of
disease states and as the proximate
cause of death
Intractable aspiration can be
managed by a variety of techniques,
reducing associated morbidity and
mortality

Identification of Aspiration
Aspiration is occasionally unrecognized as a
pathologic event up to and including the death of
the patient. Neurologic disability often masks the
usual symptoms of aspiration.
range from specific pharyngeal symptoms to
constitutional symptoms of recurrent pneumonia
and weight loss.
One of the most common symptoms is excessive
tracheal secretion after tracheotomy. It is not
uncommon for these secretions to be attributed to
bronchorrhea when the tracheal drainage is in fact
aspiration of oropharyngeal secretions.

Etiology of Aspiration
The most common cause of severe aspiration is
neuromuscular dysfunction
Patients with loss of central processing, loss of
pharyngeal muscle strength, or loss of pharyngeal
sensation are at high risk of aspiration, and
intervention is required to prevent the sequelae of
aspiration-induced pneumonia and possibly death.
University of Pittsburgh study of patients underwent
laryngotracheal separation (LTS) for intractable
aspiration more than two-thirds had devastating
neurologic disease amyotrophic lateral sclerosis,
multiple sclerosis, or brainstem stroke

 Aspiration occurs from stroke or head injury.

Patients with Parkinson disease, other movement
disorders, or specific cranial nerve deficits,
especially involvement of cranial nerves IX and X,
are likely to experience aspiration
Diseases or surgical procedures that interrupt lower
cranial nerves contribute to aspiration.
Surgical procedures that remove, modify, or
denervate structures within the oral cavity,
oropharynx, hypopharynx, or larynx are likely to
cause aspiration glossectomy, supraglottic
laryngectomy

Tracheotomy and Aspiration

Tracheostomy >
loss of the glottic closure reflex
elevated subglottic pressure during swallowing
Placing an expiratory valve on the tracheotomy tube restored
pressure
placing an expiratory speaking valve on a tracheotomy tube
decreased or eliminated aspiration during deglutition
removal, plugging, or valving a tracheotomy tube appears to
enhance swallowing
Plugging or valving of the tracheotomy tube as an initial step
in the management of dysphagia in selected patients who
are aspirating who otherwise have adequate glottic function

Sensory Loss
Sensory loss (ex:on stroke) correlates with
risk of aspiration. Air pulse sensory testing
is a reliable measure of aspiration risk and
is standard in many centers that treat
patients with neurologic impairment who
experience dysphagia and aspiration.
strategies to reduce aspiration in these
patients must include some form of
anatomic separation of the airway from
the digestive tract.

Evaluation of a Patient
Experiencing Aspiration
FESS
Barium swallow examination

Therapeutic Options
Initial Management
Nonsurgical
Nothing by mouth, feedings by nasogastric tube or
gastrostomy, management of respiratory failure, and
control of gastroesophageal reflux
Patients with respiratory failure need intubation and
mechanical ventilation. Tracheotomy and insertion of
a cuffed tracheotomy tube facilitate pulmonary toilet
After resolution of the acute process, downsizing,
removing, or valving the tracheotomy tube may
reduce aspiration

Valving of a Tracheotomy Tube

When decannulation is impossible, use of
an expiratory speaking valve may reduce
aspiration ,but This strategy is doomed for
failure when the tracheotomy tube is too
large or the cuff has not been deflated
completely
valve usage must be discontinued or
modified if aspiration into the
tracheobronchial tree is noted

Surgical Options
At the initial otolaryngologic consultation,
most patients already have discontinued
oral feeding and many have undergone
gastrostomy and tracheotomy. If
decannulation or valving of the tracheotomy
tube is not feasible or does not result in
marked improvement, or if a patient has
devastating neurologic disease, alternative
management strategies must be. These
strategies are divided arbitrarily into
adjunctive and definitive procedures

Procedures to Enhance Glottic Closure

The procedures most commonly used are
vocal cord augmentation with gelatin foam
sponge; acellular dermis, fat, or other
substances; and vocal cord medialization by
means of laryngeal framework surgery
Vocal cord medialization can be performed
with a prosthesis placed within the laryngeal
framework (thyroplasty), rotation of the
arytenoid cartilage (arytenoid adduction), or
a combination of the two procedures

Cricopharyngeal Myotomy
Cricopharyngeal myotomy can be
efficacious when radiographic
evidence of restriction at the
cricopharyngeus muscle is found,
particularly if laryngeal elevation is
unaffected by the pathologic process.

 The cricopharyngeus muscle is approached

through a low collar incision with dissection
into the prevertebral plane just anterior to the
great vessels. The cricopharyngeus muscle is
easily defined by first placing a bougie within
the lumen of the esophagus and then
palpating the muscle over the bougie
immediately posterior to the cricoid cartilage.
The cricopharyngeus muscle and the superior
fibers of the esophagus are divided down to
the mucosa of the pharynx and esophagus.
Care must be taken not to enter the lumen.

Definitive Surgical
Procedures
Definitive procedures separate the
airway and food passages, obviating
the requirement for intact neurologic
function.
laryngeal stenting
Clinical experience suggests that 2 to
3 months is the typical maximum
time that the laryngeal stent can
remain in place.
Total laryngectomy

Tracheoesophageal Diversion and

Laryngotracheal Separation
TED, Lindman -- The trachea was
divided and the proximal end was
anastomosed to the anterior esophagus
while the distal end was brought out to
the skin as it is in total laryngectomy
LTS-- performed by excising the
previous tracheostomy site and
dissecting the trachea free from the
surrounding tissue.

Soal-soal

1. A 62 year-old woman with end stage chronic

obstructive pulmonary disease is on continuous
ventilatory support. Because you performed her
tracheostomy, her physician calls to ask if she can
eat orally. You recommend.
A. A modified barium swallow
B. Consultation with a speech pathologist experienced
in swallowing evaluation in patients on chronic
ventilatory support.
C. That no attemp be made to feed her orally as it it
unlikely she will be able to swallow without adverse
effect on her pulmonary status
D. Laryngotracheal separation

2. A 93 year-old mentally alert and competent woman in

a nursing home develops an episode of aspiration
pneumonia. A modified barium swallow suggests she
has difficulties with liquids. She refuses to use
thickener with her juices and sneaks into the bathroom
for water. The preferred course of management is..
A. Restrain her in bed or a chair to prevent inappropriate
thin liquid intake
B. Assign a full-time attendant to assure she uses
thickener in all of her fluids
C. Allow her to make her own decision following
discussion of study results with her
D. Perform bilateral vocal cord Teflon injection to
enhance glottic closure

3. A 68-year old patient suffers an intracranial

hemorrhage and is slowly recovering from a
craniotomy and clot evacuation. The nurses in the
neurosurgical intensive care unit have noted tube
feedings around the tracheostomy tube. The
neurosurgical team requests a consultation for
evaluation of a suspected tracheoesophageal fistula.
Following examination you would most likely
A. Consult thoracic surgery for fistulae closure
B. Perform a laryngotracheal separation for controlof
morbid aspiration
C. Suggest changes in feeding strategies to reduce
gastropharyngeal reflux
D. Replace tracheostomy tube with one that permits
continous suction

5. A 35 year old woman suffers traumatic brain injury.

Six weeks later she is slowly developing return of
cognitive function and attempting to verbalize, but
still gastrotomy-dependent for feedings. She has a
cuffed no.8 tracheostomy tube. A first step in her
treatment to enhance swallowing would be
A. Downsize her tracheostomy tube and attempt
plugging
B. Inflate tracheostomy tube cuff and attempt feeding
her nonflavored ice cream
C. Dental rehabilitiation
D. Obtain a modified barium swallow at a nearby
hospital

6. A 47-year-old executive has been diagnosed with

amytrophic lateral sclerosis and has suffered
progression of neurologic disability but still able to do
some work at home. He is unable to speak intellegibly
or swallow and has had three episodes of aspiration
pneumonia in the past 3 months despite G-tube
feedings. The most efficacious management technique
for this patientwould be
A. Tracheotomy to facilitate pulmonary toilet
B. Tracheotomy with cuffed tracheostomy tube to
eliminate aspiration
C. Laryngotracheal separation with computerized speech
generator
D. Tracheostomy with insertion of vented laryngeal stent
to permit vocalization

7. A 59 year-old man underwent an extended

supraglottic laryngectomy 9 onths earlier and is
unable to swallow without aspiration.He is G-tubedependent and desparately desires to resume an
oral diet. Decannulation was attempted, but failed
due to glottic stenosis. Swallowing rehabilitation
would be served best by..
A. Completion laryngectomy and tracheoesophageal
puncture
B. Use of cuffed tracheostomy tube and an indwelling
glottic stent
C. Daily swallowing therapy with a home therapist
D. Fat augmentation of his vocal cords and use of an
expiratory speaking valve on his tracheostomy
tube

8. A 48 year-old woman is diagnosed with a large

vagal paraganglioma. Examination reveals
normal vocal cord function. Prevention of
postoperative aspiration can be managed best
by the performance of which of the following
procedures at the time of tumor resection?
A. Tracheostomy and insertion of a no.8 cuffed
tracheostomy tube
B. Cricopharyngeal myotomy to include the
upper 2 to 3 cm of esophageal constrictor
muscles
C. Ipsilateral medialization thyroplasty
D. Tracheostomy and insertion of glottic stent

9. A-32 year old woman with autoimmune

vasculitis suffers a brainstem stroke with
bilateral vocal cord paralysis. Her
neurologist suspects significant functional
return is likely within 6 to 8 weeks aspiration
during the acute phase of her hospitalization
and rehabilitation is best managed by..
A. Tracheotomy and laryngeal stent
B. Total laryngectomy
C. Laryngotracheal separation with
esophageal diversion
D. Placement on ventilation with paralysis,
sedation, and oral intubation

10. A 3-year old child suffered anoxic brain

injury at birth and is in a persistent
vegetative state in a chronic care facility.
Oral and tracheal suctioning is required
several times per hour. Nursing care
requirements can best be reduced by..
A. Repositioning the patient with the head
lower than the chest to facilitate drainage of
saliva
B. Laryngectomy to eliminate aspiration
C. 2 mg of atropine every 6 hours to reduce
salivation
D. Ligation of submandibular and parotid ducts

11. A 48-year-old active construction worker

presents with a T2, N1 squamous cell
carcinoma of the epiglottis and aryepiglottic
fold. Surgical management is planned.
Postoperative morbidity from aspiration can be
best prevented by..
A. Near total laryngectomy and smoking
cessation
B. 6 weeks of preoperative bronchodilator
therapy
C. Supraglottic laryngectomy with careful
attention to surgical technique
D. Cricopharyngeal myotomy with supraglottic
laryngectomy