Management of Intractable Aspiration

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Management of Intractable Aspiration

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

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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
• Dysphagia
• Neuromuscular disease
• Tumor

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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
• Superior Laryngeal Nerve
• Paralysis of CPM
• Anesthesia of supraglottis
• High Vagal Lesions - above Nodose ganglion
• Median paralyzed TVC
• Anesthesia

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Tracheostomy and Aspiration

• gt65 aspirate
• Loss of normal phasic glottic function
• Impaired glottic closure
• Decreased laryngeal elevation
• Ineffective cough
• Reduced glottic reflexes

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Intubation

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

• Endotracheal
• 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

• Definitive

• Adjunctive
• 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

• Definitive
• Stents
• Glottic closure
• Supraglottic closure
• Cricoidectomy
• Lindeman Procedure
• Double-barrel trach
• Laryngotracheal separation
• Total laryngectomy

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

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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