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Intractable Aspiration
Source : Bailey Head-neck surgeryOtolaryngology
Identification of Aspiration
Aspiration 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 Aspiration
The most common cause of severe aspiration is
neuromuscular dysfunction
Patients 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
Sensory Loss
Sensory 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 Aspiration
FESS
Barium swallow examination
Therapeutic Options
Initial Management
Nonsurgical
Nothing by mouth, feedings by nasogastric tube or
gastrostomy, management of respiratory failure, and
control of gastroesophageal reflux
Patients with respiratory failure need intubation and
mechanical ventilation. Tracheotomy and insertion of
a cuffed tracheotomy tube facilitate pulmonary toilet
After resolution of the acute process, downsizing,
removing, or valving the tracheotomy tube may
reduce aspiration
Surgical Options
At 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
Cricopharyngeal Myotomy
Cricopharyngeal 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.
Definitive Surgical
Procedures
Definitive 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
Soal-soal