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Management of Intractable AspirationSource : Bailey Head-neck surgery- OtolaryngologyAspiration pneumonia represents a major comorbidity in wide variety of disease states and as the proximate cause of deathIntractable aspiration can be managed by a variety of techniques, reducing associated morbidity and mortalityIdentification of AspirationAspiration 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 AspirationThe most common cause of severe aspiration is neuromuscular dysfunctionPatients 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 laryngectomyTracheotomy and Aspiration

Tracheostomy >loss of the glottic closure reflexelevated subglottic pressure during swallowing

Placing an expiratory valve on the tracheotomy tube restored pressureplacing an expiratory speaking valve on a tracheotomy tube decreased or eliminated aspiration during deglutitionremoval, 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 functionSensory LossSensory 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 AspirationFESSBarium swallow examination

Therapeutic OptionsInitial ManagementNonsurgicalNothing by mouth, feedings by nasogastric tube or gastrostomy, management of respiratory failure, and control of gastroesophageal refluxPatients with respiratory failure need intubation and mechanical ventilation. Tracheotomy and insertion of a cuffed tracheotomy tube facilitate pulmonary toiletAfter resolution of the acute process, downsizing, removing, or valving the tracheotomy tube may reduce aspiration

Valving of a Tracheotomy TubeWhen 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 completelyvalve usage must be discontinued or modified if aspiration into the tracheobronchial tree is noted

Surgical OptionsAt 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 ClosureThe 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 surgeryVocal 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 MyotomyCricopharyngeal 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 ProceduresDefinitive 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 SeparationTED, 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 laryngectomyLTS-- performed by excising the previous tracheostomy site and dissecting the trachea free from the surrounding tissue.

Soal-soalA 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 modified barium swallowConsultation with a speech pathologist experienced in swallowing evaluation in patients on chronic ventilatory support.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 statusLaryngotracheal separation

B2. 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 intakeB. Assign a full-time attendant to assure she uses thickener in all of her fluidsC. Allow her to make her own decision following discussion of study results with herD. Perform bilateral vocal cord Teflon injection to enhance glottic closureC3. 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 Consult thoracic surgery for fistulae closurePerform a laryngotracheal separation for controlof morbid aspiration Suggest changes in feeding strategies to reduce gastropharyngeal refluxReplace tracheostomy tube with one that permits continous suctionC5. 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 beDownsize her tracheostomy tube and attempt pluggingInflate tracheostomy tube cuff and attempt feeding her nonflavored ice creamDental rehabilitiationObtain a modified barium swallow at a nearby hospitalA6. 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 beTracheotomy to facilitate pulmonary toiletTracheotomy with cuffed tracheostomy tube to eliminate aspirationLaryngotracheal separation with computerized speech generatorTracheostomy with insertion of vented laryngeal stent to permit vocalizationC7. A 59 year-old man underwent an extended supraglottic laryngectomy 9 onths earlier and is unable to swallow without aspiration.He is G-tube-dependent and desparately desires to resume an oral diet. Decannulation was attempted, but failed due to glottic stenosis. Swallowing rehabilitation would be served best by..Completion laryngectomy and tracheoesophageal punctureUse of cuffed tracheostomy tube and an indwelling glottic stentDaily swallowing therapy with a home therapistFat augmentation of his vocal cords and use of an expiratory speaking valve on his tracheostomy tubeA8. 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?Tracheostomy and insertion of a no.8 cuffed tracheostomy tubeCricopharyngeal myotomy to include the upper 2 to 3 cm of esophageal constrictor musclesIpsilateral medialization thyroplastyTracheostomy and insertion of glottic stentC9. 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..Tracheotomy and laryngeal stentTotal laryngectomyLaryngotracheal separation with esophageal diversionPlacement on ventilation with paralysis, sedation, and oral intubation

A10. 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..Repositioning the patient with the head lower than the chest to facilitate drainage of salivaLaryngectomy to eliminate aspiration2 mg of atropine every 6 hours to reduce salivationLigation of submandibular and parotid ducts D11. 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..Near total laryngectomy and smoking cessation6 weeks of preoperative bronchodilator therapySupraglottic laryngectomy with careful attention to surgical techniqueCricopharyngeal myotomy with supraglottic laryngectomyC