A new epiglottoplasty procedure for the treatment of intractable aspiration

Intractable aspiration may require diversion of the airway from the pharynx. The epiglottoplasty procedure involves suturing the epiglottis onto the perimeter of the larynx without creating resistance to the natural lines of force of the epiglottic cartilage. The procedure starts by an anterior subhyoid pharyngotomy. The epiglottis is released from the pre-epiglottic space and the thyroepiglottic ligament is sectioned. The disinsertion is completed in the laryngeal lumen by sectioning the epiglottis on each side by following its edges. The pharyngoepiglottic folds are preserved so as to serve as the rotational axis for the freed epiglottis. The petiole of the epiglottis is anchored to the posterior commissure and the free edge of the epiglottis above the ala and the angle of the thyroid cartilage, while the lateral sides of the suprahyoid epiglottis are sutured to the superior part of the arytenoids. This procedure was performed successfully in three patients with intractable aspiration. Received: 24 October 1996 / Accepted: 26 June 1997     

Modified endoscopic swallowing test for improved diagnosis and prevention of aspiration

Laryngopharyngeal sensation is important in the normal process of swallowing, it is often impaired after neurological events and it has been common practice in such an occurrence to order non-oral tube feeding to prevent aspiration. This study assesses a novel approach to the evaluation of the laryngopharyngeal sensation that allows for improved triage of aspiration risk and more lenience towards oral feeding. This is a case series with follow-up period ranging from 6 to 24 months. Forty patients with neurological deficiencies were tested by a modified laryngopharyngeal sensation study that included evaluation of both supra and infra-glottis. All patients had impaired supra glottic sensation but had good infra glottic sensation that enabled cough protection. All had received oral feeding. Main outcome measure is incident aspiration pneumonia. Twenty-two patients maintained oral feeding without any evidence of aspiration. Eighteen patients had some aspirations associated with cough, and were maintained on modified oral feeding. Out of these 18 patients, four patients (10% of the entire group) developed aspiration pneumonia. The presented procedure identified patients with impaired supraglottic sensation but preserved good infra glottic sensation. This observation enables safe oral feeding in most patients and therefore offers a better quality of life for these individuals.     

Modified tracheoesophageal diversion for chronic aspiration

Breakdown of the normal protective function of the larynx, either through primary laryngologic or neurologic causes, leads to chronic aspiration, recurrent pneumonitis and possibly death. In this paper we discuss the existing surgical treatments for chronic aspiration. Tracheal separation and trechcocsophageal diversion are discussed, as are the difficulties of using these procedures in patients with pre-existing tracheostomies. A modification of trachcoesophageal diversion is presented whereby this procedure can now be utilized in those patients with pre-existing tracheostomies. The modified tracheoesophageal diversion is performed in five patients successfully. Since most patients have already had tracheotomies in an attempt to control aspiration, we feel that our technique of modified trachcoesophageal diversion enables this group of patients to benefit from this procedure as well.     

Modification in subtotal laryngectomy with epiglottoplasty

We describe the modification in one of the passages of the technique of subtotal laryngectomy with epiglottoplasty, consisting of the opening of larynx through the thyroid membrane. This maneuver improves the visualization of the tumor facilitating the time of its removal and later reconstruction.     

Modified laryngotracheal separation for intractable aspiration pneumonia in patients with nasopharyngeal carcinoma treated by radiotherapy

Objectives

Intractable aspiration pneumonia in patients with postradiotherapeutic nasopharyngeal carcinoma (PNC) is a formidable complication, but has not attracted enough attention in clinical practice. Modified laryngotracheal separation (MLTS) was applied for these patients in our hospital, the surgical effects of which were assessed.

Patients and methods

Retrospective analysis of 9 PNC cases complicated by intractable aspiration pneumonia in our hospital was carried out. All cases were diagnosed as lower cranial nerve palsy. Their aspiration pneumonia was not effectively prevented or controlled after a series of previous treatments, including active anti-infectives, neurotrophy, acupuncture, nutrition support, nasogastric feeding and tracheotomy. Ultimately all of them received modified laryngotracheal separation (MLTS) surgery. Efficacy of the operation was assessed.

Results

In all patients, aspiration pneumonia was effectively controlled after the operation, body weights increased more than 6 kg six months later, and nutrition status, swallowing function and quality of life were all improved.

Conclusions

Intractable postradiotherapeutic aspiration pneumonia in patients with nasopharyngeal carcinoma was possibly caused by lower cranial nerve palsy, which might be related to radiation fields overlapped. Modified laryngotracheal separation is effective in eliminating intractable aspiration in PNC. Suitable patients should be carefully selected although the procedure is potentially reversible.     

改良支撑管在喉外伤和喉气管狭窄中的应用

目的：探讨改良支撑管在喉外伤和喉气管狭窄中减少并发症及喉气管裂开次数的作用。方法：经各种不同方式行喉气管重建术，术中全部放入改良硅橡胶支撑管治疗急性严重喉气管外伤23例及慢性喉气管狭窄8例。结果：31例全部成功拔管，治愈率为100％。无呼吸道阻塞及严重误吸等并发症发生。6例第2次拔管者均是在第1次拔管时，同期经声门再次置入改良支撑管后治愈，避免了再次喉气管裂开术。结论：改良支撑管在预防和治疗喉气管狭窄中具有能保证呼吸道畅通，减少喉气管裂开术次数等优势。但拔管前不能发声是其缺点。     

Subglottic laryngeal closure for aspiration

Aspiration may be life threatening, particularly in those patients with severe central neurological disease. From such a group of patients, several were identified who had severe laryngeal dysfunction and aspiration. The majority of patients in this subgroup existed in a neurologically vegetative state. In an attempt to reduce the degree of aspiration they experienced, the procedure of subglottic laryngeal closure was performed. Essentially, the operation is designed to isolate the tracheal airway from the incompetent larynx. The aim is to protect the lower airway from pharyngeal contamination. In all 5 patients there was a marked improvement in general and pulmonary health.     

Staple-assisted laryngectomy for intractable aspiration

Staple-assisted laryngectomy is a unique method previously reported by Lukyanchenko to prevent wound contamination by using a stapling device for suturing pharyngeal defects in total laryngectomy. We have modified his method and applied it to prevent a postoperative pharyngocutaneous fistula in the treatment of intractable aspiration. In contrast to laryngeal cancer patients, a combined use of an intraluminal light to guide the dissection and laryngofissure to pull the epiglottis can be used to facilitate the use of the stapling device. For most patients with intractable aspiration who have significant malnutrition and drug-resistant bacterial colonization of the pharynx, this method offers certain advantages. This report describes our successful experience with this method in the management of patients with intractable aspiration.     

Epiglottic plication for intractable aspiration

We describe a procedure to plicate the epiglottis into a vertical tube to prevent soiling of the airway due to intractable aspiration. The procedure is combined with an extensive cricopharyngeal myotomy. This technique allows laryngeal speech, even with a tracheostomy, and in some patients may allow the reversal of the tracheostomy. It is only suitable for a small proportion of patients with marked aspiration, as most will respond to conservative treatment. Nine patients underwent this operation and six gained a satisactory result, with two patients achieving tracheostomy reversal. There were two late post-operative deaths from infective causes which reflects the general debiliation of these patients and the risk of exacerbating concomitant broncho-pulmonary infection.     

Triple-layer laryngeal closure for intractable aspiration

Impaired laryngeal protective function can result in intractable aspiration, which causes recurrent life-threatening pneumonia. Several surgical operations have been developed to treat intractable aspiration. In this case, we report a successful case of triple-layer laryngeal closure, which was performed in a patient with type II diabetes mellitus and nutritional failure due to intractable aspiration that had been caused by several stroke attacks. Triple-layer laryngeal closure is a unique modified technique that combines laryngotracheal separation and glottic closure operations. The method that we performed can be done more safely in patients who have higher post-operative and general anaesthesia risks.     

Laryngotracheal reconstruction. Extended vertical partial laryngectomy: reconstruction combining epiglottoplasty and the rotary door flap.

This article explores various surgical techniques for vertical, partial laryngectomy in the treatment of laryngeal cancer. Potential for reconstruction and broader indications for such surgical procedures may be achieved by combining laryngeal epiglottoplasty with the rotary door sternohyoid myocutaneous flap.