Chronic AspirationChronic AspirationDr.Sherif BugnahDr.Sherif Bugnah

ENT ResidentENT Resident

Armed Forces Hospitals Southern Region Armed Forces Hospitals Southern Region

Khamis Mushayt - Saudi ArabiaKhamis Mushayt - Saudi Arabia

Symptoms Evaluation Nonsurgical management Surgical management

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)

Introduction Aspiration is tolerated if:

Normal tracheobronchial clearance Normal defense mechanisms

Bronchopulmonary complications Volume Character of aspirate (ph, bacterial)

Bronchospasm, tracheitis, bronchitis, pneumonia, pulmonary abscess, sepsis, death

“At Risk” Patients Impaired swallowing or airway protection

Temp. Neurologic dysfunction Drugs, etoh, metabolic derangement

Sz, or infection Age – elderly > risk

Physiologic, neurologic changes (aviv et al., 1994; blitzer, 1990)

“At Risk” Patients Denture patients

Impaired sensation Impaired oral control

Chronic aspiration Repeated episodes Requires rapid recognition & effective management to

prevent complications

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

Causes of Chronic AspirationCauses of Chronic Aspiration

Causes of Chronic Aspiration (Pediatric): CP, Anoxic Encephalopathy, Congenital Or Acquired Disorders Sequelae From Neurotrauma TE Fistula Surgery,

Coughing or choking during swallowingCoughing or choking during swallowing Silent aspiration – no symptomsSilent aspiration – no symptoms FeverFever Productive cough with purulent sputumProductive cough with purulent sputum Weight lossWeight loss DysphagiaDysphagia OdynophagiaOdynophagia

MultidisciplinaryMultidisciplinary SLP, Neurology, Internal SLP, Neurology, Internal

Medicine, Rehab. Medicine, Rehab. Medicine, Radiology, GI, Medicine, Radiology, GI, Thoracic Surgery, Thoracic Surgery, PsychiatryPsychiatry

Medical History, Prior Medical History, Prior Surgery Or InjurySurgery Or Injury

Head & Neck With CN Head & Neck With CN EvaluationEvaluation

Larynx & PharynxLarynx & Pharynx esophagoscopy if indicatedesophagoscopy if indicated PFTs – pulmonary fx & PFTs – pulmonary fx &

reservereserve

• CXR, MBS with esophagram CXR, MBS with esophagram (VFS)(VFS) (D.Silbiger, 1966; (D.Silbiger, 1966;

Splaingard 1998)Splaingard 1998) small amt. of barium if at small amt. of barium if at

risk risk (Logemann, 1986)(Logemann, 1986) different consistencies different consistencies

(with SLP)(with SLP)

reduce aspirationreduce aspiration treatment plan (dx and treatment plan (dx and

therapy)therapy) Scintigraphy Scintigraphy (Muz et al., (Muz et al.,

1987, Stachler et al., 1996)1987, Stachler et al., 1996)• CT or MRICT or MRI• fix correctable causes (CP fix correctable causes (CP

spasm, Zenker’s, spasm, Zenker’s, obstructions)obstructions)

AntibioticsAntibiotics Aggressive pulmonary therapyAggressive pulmonary therapy NPO, alternative route of nutritionNPO, alternative route of nutrition

NG TubesNG Tubes Does not eliminate risk of aspiration Does not eliminate risk of aspiration (ciocon jo et al., 1988) (ciocon jo et al., 1988) May increase aspiration May increase aspiration (Alessi, Berci., 1986; Elpern et al., 1987)(Alessi, Berci., 1986; Elpern et al., 1987)

Cervical Esophagotomy, Piriform Sinusotomy, Gastrostomy, Cervical Esophagotomy, Piriform Sinusotomy, Gastrostomy, JejunostomyJejunostomy

G TubesG Tubes does not decrease aspiration in does not decrease aspiration in

neurologically impaired patients neurologically impaired patients (Hassett et al., 1988; Kadakia et al., 1992)

Not indicated if GI tract not fx.Not indicated if GI tract not fx.hyperalimentation (eg: severe anoxic brain injury)hyperalimentation (eg: severe anoxic brain injury)

Special Nursing CareSpecial Nursing Care positioningpositioning

elevation of the elevation of the HOBHOB if reflux if reflux difference with difference with endotracheal tubeendotracheal tube(Elpern et al., 1987)(Elpern et al., 1987)

frequent suctioning of the oral cavity & oropharynxfrequent suctioning of the oral cavity & oropharynx

chronic aspiration continued soilage surgical separation may be necessary

reasonable survival duration of survival

medical status mental status severity of illness quality of life

Sacrifices normal phonation & laryngeal respiration vs.

airway protection patient, family & caregiver discussions

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

Surgical Management

TracheotomyTracheotomy Vocal Cord Vocal Cord

MedializationMedialization LaryngectomyLaryngectomy Subperichondrial Subperichondrial

CricoidectomyCricoidectomy Partial CricoidectomyPartial Cricoidectomy

Stents Stents Epiglottic Flap ClosureEpiglottic Flap Closure LaryngoplastyLaryngoplasty Glottic Closure Glottic Closure Tracheoesophageal Tracheoesophageal

Diversion Diversion

Provides airway controlProvides airway control Pulmonary toiletPulmonary toilet Reduces dead spaceReduces dead space

Cuffed tubes Cuffed tubes Do not prevent aspirationDo not prevent aspiration Impairs laryngeal elevation and effective coughImpairs laryngeal elevation and effective cough bypass of upper airway – impairs reflex laryngeal bypass of upper airway – impairs reflex laryngeal

closureclosure Sasaki CT et al., 1977; Shaker R., 1995

low pressure/ high compliance cuffs – minimize cuff low pressure/ high compliance cuffs – minimize cuff leak /leak / does not prevent aspiration does not prevent aspiration (Bernhard WN et al., 1979; Pavlin et al., 1975; Petring et al., 1986)

Vocal fold paralysis esp. Sensory deficitVocal fold paralysis esp. Sensory deficit Endoscopic, Transcervical ApproachEndoscopic, Transcervical Approach

medializes cordsmedializes cords prevents aspiration prevents aspiration (Lewy, 1964; McCaffrey, L., 1989; Rontal, 1976)

Medialization LaryngoplastyMedialization Laryngoplasty

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

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

Subperichondrial Cricoidectomy

Subperichondrial Cricoidectomy Advantages: high success rate

simplicity low morbidity local anesthesia

Disadvantages: fistula into upper trachea tracheostomy needed reversibility difficult

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

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

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

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.

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

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)

Epiglottic Flap Closure

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)

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)

Vertical Laryngoplasty

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)

Glottic Closure

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

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.

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

Tracheoesophageal Diversion

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

Modified TE Diversion ant. tracheal flap: inferior half of cricoid & ant. 1st & 2nd tracheal rings removed end to end anastomosis to ant. esophagus

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

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

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)