Chronic Aspiration Drbugnhah

Chronic Aspiration Dr.Sherif Bugnah ENT Resident Armed Forces Hospitals Southern Region Khamis Mushayt - Saudi Arabia

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Symptoms Evaluation Nonsurgical management Surgical management

Introduction 

3 main functions of larynx  Respiration  Phonation  Airway

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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,

 Sz, 

etoh, metabolic derangement

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 Aspiration

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Causes of Chronic Aspiration (Pediatric):  CP,

Anoxic Encephalopathy,  Congenital Or Acquired Disorders  Sequelae From Neurotrauma  TE Fistula  Surgery,

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Coughing or choking during swallowing Silent aspiration – no symptoms Fever Productive cough with purulent sputum Weight loss Dysphagia Odynophagia

Multidisciplinary SLP, Neurology, Internal Medicine, Rehab. Medicine, Radiology, GI, Thoracic Surgery, Psychiatry Medical History, Prior Surgery Or Injury

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Head & Neck With CN Evaluation Larynx & Pharynx esophagoscopy if indicated PFTs – pulmonary fx & reserve

 reduce

•

CXR, MBS with esophagram (VFS) (D.Silbiger, 1966; Splaingard 1998)  small amt. of barium if at risk (Logemann, 1986)  different consistencies (with

aspiration  treatment plan (dx and therapy)  Scintigraphy (Muz et

• •

al., 1987, Stachler et al., 1996)

CT or MRI fix correctable causes (CP spasm, Zenker’s, obstructions)

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Antibiotics Aggressive pulmonary therapy NPO, alternative route of nutrition  NG 

Tubes

Does not eliminate risk of aspiration (ciocon jo et al., 1988)

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May increase aspiration (Alessi, Berci., 1986; Elpern et al., 1987)

 Cervical

Esophagotomy, Piriform Sinusotomy, Gastrostomy, Jejunostomy

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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

brain injury)

(eg: severe anoxic

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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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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

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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

Surgical Management

 Tracheotomy  Vocal

Cord Medialization  Laryngectomy  Subperichondrial Cricoidectomy  Partial Cricoidectomy

 Stents  Epiglottic

Flap

Closure  Laryngoplasty  Glottic Closure  Tracheoesophageal Diversion

Provides  

airway control Pulmonary toilet Reduces dead space

 Cuffed tubes  Do not prevent aspiration  Impairs laryngeal elevation and effective cough  bypass of upper airway – impairs reflex laryngeal closure Sasaki CT et al., 1977; Shaker R., 1995

 low

pressure/ high compliance cuffs –

Vocal fold paralysis esp. Sensory deficit  Endoscopic, Transcervical Approach 

 

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

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Medialization Laryngoplasty

Laryngectomy 

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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 

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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 

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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 

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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 

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posterior inlet left open for phonation (Brooks, McKelvie, 1983; Vecchione et al., 1975) mandibular suspension of larynx  increases

1986)

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protection (Warrick-Brown et al.,

false vocal fold approx. (Cummings et al., 1984) success: only 50%, failures can be revised reports of reversal with endoscopy (Stome

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 

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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

Vertical Laryngoplasty

Glottic Closure    

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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.,

Glottic Closure

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

Glottic Closure 

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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

Tracheoesophageal Diversion  

Lindemann (1975) objectives: reliable technique for aspiration,  preserve

larynx & RLNs  reversible potentially  

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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 

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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 

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Indications: chronic aspiration without high tracheostomy allows penetrated secretions to pass to esophagus separation technically easier complications: fistula – local care with abx. 

TE Diversion 

Reversal: neurologic improvement  VFSS,

laryngoscopy  post CVA, benign tumor resection (Eisele et al., 1989) 

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Advantages: dependable, oral alimentation, reversible, children Disadvantages: transcervical, loss of air powered speech, (BS prosthesis – manual dexterity, visual acuity)