Management of Intractable Aspiration

Robert H. Stroud, M.D. Anna M. Pou, M.D. October 18, 2000

Physiology of Swallowing

Oral preparatory phase Oral phase Pharyngeal phase Esophageal phase

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Oral Preparatory Phase

Break down food Mix with saliva Prevent premature escape into pharynx

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Oral Phase

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Pharyngeal Phase

Velopharyngeal closure Laryngeal closure Peristalsis Laryngeal elevation Opening of CPM

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Esophageal Phase

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Incidence

10% - 20% of patients with GERD 69% tracheotomy patients 7% of patients receiving GA Occurs in some normal individuals while sleeping

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Predisposing Conditions

Reduced level of consciousness

Trauma CVA Neuromuscular disease Tumor

Dysphagia

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Post-Surgical Aspiration

Skull base Central nervous system Head and Neck

Partial pharyngectomy Glossectomy Supraglottic laryngectomy Palate Tonsillar pillars

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Cranial Nerve Deficits

V Oral preparatory phase VII - Oral preparatory phase IX Pharyngeal Phase X Pharyngeal Phase XII Oral Phase

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Vagus Defects

Recurrent Laryngeal Nerve

Paramedian TVC Paralysis of CPM Anesthesia of supraglottis Median paralyzed TVC Anesthesia

Superior Laryngeal Nerve

High Vagal Lesions - above Nodose ganglion

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Tracheostomy and Aspiration

>65% aspirate Loss of normal phasic glottic function Impaired glottic closure Decreased laryngeal elevation Ineffective cough Reduced glottic reflexes

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Intubation

Nasogastric

Endotracheal

Post-cricoid edema Suppressed cough reflex Pooling Dysfunction of UES and LES

40% aspirate Inflated cuff does not prevent aspiration

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Signs and Symptoms

Recurrent pneumonia Bronchorrhea Coughing and choking with eating Dysphagia Weight loss Silent aspiration

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Diagnosis

Mendelsons Syndrome gastric acid aspiration

Tachypnea Cough Rales Cyanosis Wheezing fever

Particulate matter mechanical obstruction Oropharyngeal secretions pneumonia

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Evaluation

History and Physical

Cranial nerves Pooling of secretions

Grape juice/Blue dye test Chest radiograph Radionucleotide scanning

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Modified Barium Swallow

Evaluates entire swallow Varied consistencies used Efficacy of therapeutic maneuvers assessed

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Normal Modified Barium Swallow

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Oral Phase Dysfunction

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Fiberoptic Assessment of Swallowing

FEES, VEED, FEESST Pharyngeal phase only Varied consistencies of materials Portable Complementary to MBS

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Non-Surgical Management

NPO Feeding tube Tracheostomy for prolonged intubation Postural change Dietary modifications

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Management of the Aspirating Tracheostomy Patient

Speaking valve

Subglottic pressure Return of glottic reflexes

Decannulation

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Swallow Techniques

Supraglottic
Deep inspiration swallow cough swallow inspiration

Chin tuck compresses valleculae Head turn toward unilateral pharyngeal weakness - compresses pyriform

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Surgical Management

Adjunctive

Definitive

Tracheostomy Feeding tube Ligation salivary ducts Laryngeal suspension Cricopharyngeal myotomy Cricoid Resection TVC medialization
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Laryngeal Suspension

Usually at time of extirpative surgery Moves larynx superiorly and anteriorly Suspend hyoid or thyroid lamina to mandible

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Cricopharyngeal Myotomy

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Cricoid Resection

Submucosal dissection Resection of posterior lamina of cricoid Performed with CPM Reduced AP laryngeal dimension, enlarged hypopharyngeal inlet

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Vocal Cord Injection

Gelfoam Autogenous Fat Teflon

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Thyroplasty

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Arytenoid Adduction

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Surgical Management

Adjunctive

Definitive

Tracheostomy Feeding tube Ligation salivary ducts Laryngeal suspension Cricopharyngeal myotomy Cricoid Resection TVC medialization
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Stents Glottic closure Supraglottic closure Cricoidectomy Lindeman Procedure Double-barrel trach Laryngotracheal separation Total laryngectomy

Eliachar Laryngeal Stent

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Glottic Closure

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Supraglottic Closure - Biller

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Epiglottic Flap

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Subperichondrial Cricoidectomy - Eisele

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Lindeman Procedure

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Double-Barrel Tracheostomy

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Laryngotracheal Separation

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Total Laryngectomy

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Conclusion

Wide variety of etiologies Diagnose causation Tailor management Prevent morbidity and mortality

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