Diverting the paralyzed larynx: A reversible procedure for intractable aspiration.

Some unfortunate patients suffer disorders which in one way or another, usually neurologically, severely restrict the larynx in its role as a protector of the lower airway. Aspiration ensues, and unless it can be successfully managed, repeated episodes of a violent pneumonitis may lead to terminal chest problems. In some patients, even the cuffed tracheostomy tubes of new and improved design do not adequately prevent aspiration over an extended time interval, as evidenced by repeated bouts of aspiration pneumonia despite these cuffed tubes and despite optimal intensive care. For these patients with intractable aspiration, and in whom recovery is expected only after a prolonged period of time, we have suggested a diverting procedure which employs a tracheo-esophageal anastomosis, as an effective yet reversible solution. Such an anastomosis with concomitant tracheostomy allows aspiration of saliva and even food to occur through the malfunctioning larynx but diverts it back into the esophagus through the tracheo-esophageal anastomosis. In normal mongrel dogs we demonstrated that an end-to-side tracheoesophageal anastomosis is well tolerated and can be performed without damage to the intrinsic larynx or recurrent laryngeal nerves. The tracheoesophageal lumen remained patent and the anastomosis intact for as long as these animals were observed prior to reconstruction. The reversibility of the tracheo-esophageal anastomosis was demonstrated in these dogs by excising the anastomosis, repairing the esophageal defect, and restoring the continuity of the trachea by end-to-end anastomosis. Vocal cord motion remained intact, the dogs ate normally, and barked once again. A tracheo-esophageal anastomosis was performed in a 60-year-old white female who had suffered lower cranial nerve damage as a result of a large acoustic tumor and the excision thereof. Despite every effort to control aspiration, pneumonitis occurred and became fulminant. The diverting tracheo-esophageal anastomosis was performed with relative ease and was well tolerated by the patient. Aspiration was totally and dependably controlled, and no further chest complications occurred. Her nasogastric feeding tube was removed, and she ate a regular diet with very little difficulty. She gained in strength, became much more alert mentally, and is now taking care of herself in a nursing home. We are following her progress by indirect laryngoscopy and barium swallow examinations and at five months post anastomosis, we are possibly seeing the first signs of lower cranial nerve recovery. We hope that reconstruction and restoration of function will soon be possible. We feel that the results to date of our animal experimentation and of our case report are satisfactory. Many questions remain unanswered, however, and for this reason we must emphasize a very conservative approach to the clinical application of this procedure.