Surgical Management of Chronic Aspiration Treatment & Management

Medical therapy frequently requires the interdisciplinary cooperative efforts of medicine, otolaryngology, gastroenterology, speech therapy, radiology, physiatry, and neurology specialists.

Usually, the first step in the medical management of chronic aspiration is the treatment of bronchopulmonary complications (eg, pneumonia). This treatment may entail antibiotic therapy that covers anaerobic and pseudomonal species and intubation for ventilatory support and intensive care. Once the patient stabilizes, the severity, source, pathologic etiology, and chronicity of the aspiration is determined.

Until a swallowing evaluation is completed, allow the patient nothing by mouth (NPO). Consider alternative methods of alimentation that use the gut (when functional). Methods include gastrointestinal feeding tubes via the nose or mouth and percutaneous gastrostomy or jejunostomy. Since alimentary feeding tubes do not eliminate the risk of aspiration (as with orogastric/nasogastric tubes) and actually may increase the aspiration by elimination of the protective action of the esophageal sphincters, reflux precautions must be strictly followed. Reflux precautions include placing the bed in a high Fowler position, especially during and after feedings; maintaining slow drip rather than rapid bolus feedings (or small frequent feedings); and administering medication.

Antiemetics, H2 antagonist, and proton pump inhibitors are frequently used. Hyperalimentation may be used in individuals who are not alimentary feeding candidates. Pursue aggressive pulmonary toilet (including frequent suctioning) in both intubated and nonintubated patients with aspiration.

A study by Adil et al recommended that children suffering from chronic aspiration who have normal upper airway anatomy be treated with feeding and swallowing therapy. The study, which involved 46 patients (mean age 1.56 years)—including eight who were syndromic, 16 with developmental delay, and 12 who had congenital heart disease—found that swallowing dysfunction was resolved in 36 (78.3%) of them through feeding and swallowing therapy, with three patients requiring a tracheostomy. ^[11]

Tracheotomy

Tracheotomy is indicated in both chronic aspiration and pulmonary complications requiring sustained ventilatory support. This procedure is also indicated in relief of upper airway obstruction, in prolonged need for ventilatory support, in obstructive sleep apnea, and for pulmonary hygiene.

A tracheotomy does not prevent aspiration. In 1999, Schonhofer et al reported a 30% aspiration rate in patients who were tracheotomized. ^[12] The presence of a tracheotomy tube can increase aspiration risk via limitation of laryngeal elevation and anterior-superior excursion during swallowing. ^[13] A cuffed tracheotomy tube further increases this risk and the risks of mucosal ulceration, tracheal stenosis, and chondritis. These risks have been minimized with the advent of high-volume, low-pressure cuffs.

After achieving an adequate level of general endotracheal anesthesia, the patient is positioned with a shoulder roll to assist with obtaining adequate neck extension for exposure. The patient is usually then prepared and draped in a sterile fashion. Local anesthetic containing epinephrine is injected along the proposed incision site. The neck is then prepped and draped in a sterile fashion.

An incision is made either vertically in the midline or horizontally in a skin fold centered halfway between the cricoid cartilage and the sternal notch in most patients. The incision is carried through the skin, subcutaneous tissue, and platysma muscle to the level of the strap muscles. The relatively avascular midline raphe of the strap muscles is identified and strap muscles are retracted laterally. The thyroid isthmus is either retracted or divided, depending on its position in relation to the tracheal rings.

In adults, a cricoid hook can be used to assist with superior retraction. This is not advised in young children due to the risk of injury to the cricoid cartilage. A variety of anterior tracheal wall incisions can be used. In children, before making an incision, safety retraction sutures are placed on either side of the midline at the third/fourth tracheal ring level, then the incision is made vertically through the third, fourth, and sometimes the fifth tracheal ring.

The safety sutures are kept long, labeled right and left, and at the conclusion of the surgery are secured to the anterior chest wall on either side for use in case of accidental decannulation. In adults, one common method is to create an anterior window, removing the central/anterior portion of the third and sometimes the fourth tracheal rings. Alternatively, instead of removing the window, it is left with an inferior attachment and sutured to the skin. Both in children and in adults, the edges of the tracheal incision can be sutured to the skin in all 4 quadrants as a method to decrease the time to stomal maturation and decrease the risk of false passage creation in the event of the accidental decannulation.

At this juncture, the endotracheal tube is withdrawn, and a tracheotomy tube is inserted. The tracheotomy tube is appropriate to both the patient's age and the size of the trachea. It is fastened to the patient using tracheotomy tape with a finger breadth of room under the tie. Foam padding may be placed under the ties to prevent skin breakdown. In adults, the tracheotomy plate can be sutured to the skin.

Complications include wound infection, bleeding, hematoma, tracheotomy tube plugging, accidental decannulation, and pneumothorax.

Postoperative care includes frequent suctioning with precautions to prevent decannulation, especially until the tract has matured, usually within 3-7 days. Tracheostomy site cleaning helps to prevent development of granulation around the tube. As part of home discharge planning, home caregivers need to be educated regarding tracheotomy care, cleaning, and emergency procedures.

Laryngectomy

Billroth performed the first laryngectomy in 1873 for laryngeal carcinoma. ^[14] Laryngectomy was once the mainstay of surgical intervention for aspiration. However, the loss of phonation, laryngeal respiration, and irreversibility of the procedure has limited its use. In 1990, Dedo, who no longer performs laryngotracheal separation (LTS) for aspiration because reconnection was not accomplished in his population, stated that the inability of patients who underwent LTS to phonate and the inability to insert voice prosthesis were considerations in his decision to return to laryngectomy for treatment of aspiration. ^[15]

Laryngectomy is most commonly used for aspiration when life-threatening aspiration occurs or is at high risk of occurring following surgical management of head and neck tumors (especially of the oropharynx); it is occasionally used in progressive neurologic conditions that have irreversibly impaired swallowing. Laryngectomy would not be the treatment of choice when a reasonable chance for functional improvement in the patient’s swallowing function exists. ^[16]

The first decision in preparing a patient for laryngectomy for chronic aspiration is to choose an incision type. The apron flap incision (which incorporates the previous tracheostomy stoma) is commonly used as a tracheotomy and is often performed in patients with chronic aspiration. The incision starts from the mastoid tip to the level of the stoma, then curves upward to the contralateral mastoid tip following the edge of the sternocleidomastoid (SCM) muscle for the vertical portion and a natural skin crease at the horizontal anterior neck portion. The skin flaps are then elevated in the subplatysmal plane.

In general, a narrow field of resection is performed, and the hyoid, strap musculature, and the hypopharyngeal mucosa are preserved. ^[17] The larynx is skeletonized after separation of the strap muscles in the midline and division with ligation of the thyroid isthmus. Following this step, the thyroid is released from the ligamentous attachments to the larynx and the trachea.

The posterior border of the thyroid cartilage is exposed, and the inferior constrictor muscle attachment to the thyroid cartilage is identified. Subsequently, the attachment is released along the ala of the thyroid cartilage. The superior laryngeal nerve with accompanying artery and vein are ligated and divided bilaterally. The superior horn of the thyroid cartilage is identified, and the piriform sinus mucosa is dissected free of the thyroid cartilage bilaterally. The thyrohyoid membrane is incised along the inferior border of the hyoid, and the larynx is mobilized. The trachea is transected at the level of the previous stoma, and the posterior trachea along with the cricoid cartilage is carefully separated from the esophagus. The anterior wall of the distal tracheal segment is then sutured to the skin with a heavy suture, and an armored tube is placed.

The pharynx is entered via the piriform sinus or the vallecula. Alternatively, the pharynx may be entered at the arytenoids, with a limited infrahyoid pharyngotomy performed. This allows preservation of the pharyngeal mucosa in vallecula, aryepiglottic, and postcricoid areas. However, the classic incision is carried along the walls of the sinuses medially and along the vallecula and epiglottis superiorly. Once the level of the cricoid cartilage is reached, the incisions are joined (ie, superior and inferior incisions), and the larynx is removed. The pharynx is then closed using an inverted running-type Connell stitch with 3-0 Vicryl over a nasogastric tube. The constrictor muscles are sutured in a similar fashion to provide for a second-layer closure.

Suturing the skin edges to the tracheal mucosa without tension forms the permanent tracheostome. This may require defatting of the adjacent skin and/or subcutaneous tissue. Lastly, the wound is closed in layered fashion with reapproximation of platysmal, subcutaneous, and epidermal layers. If a tracheotomy was originally present in the skin flap, excision of the scarred tissue is required, and the defect is repaired as meticulously as possible.

Complications include pharyngocutaneous fistula, infection, stomal stenosis, and subcutaneous hematoma.

For postoperative care, the wound drainage is monitored. Drains are discontinued when minimal drainage is noted. Wounds are covered with topical antibiotic ointment. Sutures are removed in 7-10 days. Care of the tracheostome is as previously noted. Systemic antibiotics are administered postoperatively for 3 doses. Prior to discharging the patient from the hospital, methylene blue or radiographic swallow studies may be performed to exclude subclinical pharyngeal or esophageal leakage.

Phonation may be restored postoperatively with minimal aspiration risks by using the Blom-Singer prosthesis via tracheoesophageal puncture.

In 1997, Krespi and Blitzer reported on 10 patients who were treated with this technique after other procedures had failed for aspiration; this technique was successful in all 10 patients. ^[18]

Total and partial cricoid resection

Partial cricoid resection is usually performed as an adjunct procedure during reconstruction of the oropharynx after tumor resection. In 1993, Cummings proposed subperichondrial cricoidectomy instead of laryngectomy. ^{[19, 20, 21]}

Indications for this procedure include chronic aspiration with poor or no chance of recovery.

Contraindications to total or partial cricoid resection include good prognosis for neurologic recovery or return of swallowing capability.

For a total cricoidectomy, the patient is prepared in a similar fashion to that of a tracheotomy. A midline neck incision or an apron incision is performed to the level of the strap muscles and the trachea. The tracheostome is performed, as previously described, and the cricoid ring is identified. The cricoid is incised anteriorly and is grasped with skin hooks. The cricoid cartilage is then removed after elevation of the cartilage in the subperichondrial plane. The inner perichondrium is closed, and the mucosa is sutured after infolding the cut ends. The sternohyoid muscle is placed between the proximal and distal stumps, and the outer perichondrium is closed. Neck closure is performed in a layered fashion, as previously described. ^[19]

Partial cricoidectomy is approached as described above, except only a submucosal segment of the posterior cricoid cartilage is resected and a cricopharyngeal myotomy is performed.

Complications include pharyngotracheal fistula, wound infection, bleeding, hematoma, and pneumothorax.

Postoperative care is similar to that following a tracheotomy (see Tracheotomy above). Adequate wound care must be provided. Sutures are removed in 7-10 days. Antibiotics are administered postoperatively for 3 doses.

Laryngeal closures

Habal and Murray described the creation of an epiglottic flap for laryngeal closure in 1972, and, in 1983, they described a supraglottic closure with an epiglottic flap. ^[3] In 1975, Montgomery described a glottic closure technique that entails a midline thyrotomy with suturing of the true vocal cords, ventricles, and posterior commissure. ^[22]

Since that time, both endoscopic and external approaches have been described to perform either epiglottic or glottic closure procedures.

The epiglottis can be sutured over the glottis, and/or the vocal cords can be closed with sutures. These procedures require an alternate route of respiration, and a tracheotomy is required. These procedures are reversible, and they should be used in the setting of a reasonable expectation of return of functional laryngeal protection by the vocal folds.

Supraglottic closure with epiglottic flap

Indications include aspiration secondary to glottic incompetence. Contraindications to this procedure are chronic aspiration with a poor recovery prognosis.

During the procedure, a lateral pharyngotomy approach is undertaken, and the epiglottis is sutured to the aryepiglottic folds and arytenoids. Careful denuding of these areas at the points of contact is undertaken prior to suturing. The base of the epiglottis may be scored to lessen its elasticity.

Although dehiscence of the flap may ensue, botulinum toxin injection is reportedly a useful adjunct to limit vocal fold movement in prevention of this complication. ^[23]

Following surgery, patients should receive tracheotomy care, postoperative antibiotics, wound care, and, when appropriate, drain removal. Patients should be monitored for dehiscence with recurrent aspiration.

Glottic closure

Indications include aspiration secondary to glottic incompetence.

Contraindications to this procedure are chronic aspiration with a poor chance of recovery.

During the procedure, a midline thyrotomy is performed, and the true cords, ventricles, and arytenoids are denuded of epithelium. The larynx is closed with sutures, passing through the thyroid cartilage, the anterior commissure ipsilaterally to the contralateral side through the vocal cord, and the arytenoid cartilage. Sutures then pass back through the posterior portion of the ipsilateral cord and the thyroid cartilage. The other side is similarly addressed, and the thyrotomy is closed in a standard fashion. ^[22]

Complications include an inability to reverse secondary to severe glottic scarring (see Tracheotomy above).

Patients should receive adequate care following surgery, including tracheotomy care, postoperative antibiotics, and wound care.

Vocal outcomes

A study by Ku et al of patients with chronic aspiration after radiotherapy for head and neck cancer found that those who subsequently underwent tubed supraglottic laryngeal closure (TSLC) surgery had better voice and speech quality than did patients who were treated with total laryngectomy and a voice prosthesis. Voice and speech ratings, as measured on the GRBAS (Grade of hoarseness, Roughness, Breathiness, Asthenia, and Strain) and INFVo (Impression, Intelligibility, Noise, Fluency, and Voice) scales, did not differ by a statistically significant amount between preoperative individuals and post-TSLC patients. However, deterioration of voice quality did seem to occur after TSLC. The investigators found, though, that INFVo scale scores were statistically significantly better in the TSLC patients than in the laryngectomy/prosthesis group. ^[24]

Tracheoesophageal diversion

Lindeman originated tracheoesophageal diversion (see History of the Procedure).

This procedure is indicated for patients with severe, life-threatening, chronic aspiration who have a potential for recovery from the disease process that causes aspiration.

Contraindications to tracheoesophageal diversion include upper tracheal pathology.

The most common incision used is an apron type that allows for easy incorporation of the tracheostomy stoma in patients who have had prior tracheostomy placement. The incision starts along the posterior edge of one sternocleidomastoid muscle superior to the stoma, curves down to the stoma and then curves upward on the contralateral side following the edge of the sternocleidomastoid (SCM) muscle. The skin flaps are then elevated in the subplatysmal plane.

When performing laryngectomy for aspiration, a narrow field of resection is performed, and the hyoid, strap musculature, and the hypopharyngeal mucosa are preserved. ^[17] The larynx is skeletonized after separation of the strap muscles in the midline. The thyroid isthmus is divided and the thyroid is released from the ligamentous attachments to the larynx and the trachea.

The posterior border of the thyroid cartilage is exposed, and the inferior constrictor muscle attachment to the thyroid cartilage is identified. Subsequently, the attachment is released along the ala of the thyroid cartilage. The superior laryngeal nerve with accompanying artery and vein are ligated and divided bilaterally. The superior horn of the thyroid cartilage is identified, and the pyriform sinus mucosa is dissected free of the thyroid cartilage bilaterally. The thyrohyoid membrane is incised along the inferior border of the hyoid, and the larynx is mobilized. The trachea is transected at the level of the previous stoma, and the posterior trachea along with the cricoid cartilage is carefully separated from the esophagus. The anterior wall of the distal tracheal segment is then sutured to the skin with a heavy suture, and an armored tube is placed.

The pharynx is entered via the piriform sinus or the vallecula. Alternatively, the pharynx may be entered at the arytenoids, with a limited infrahyoid pharyngotomy performed. This allows preservation of the pharyngeal mucosa in vallecula, aryepiglottic, and postcricoid areas. However, the classic incision is carried along the walls of the sinuses medially and along the vallecula and epiglottis superiorly. Once the level of the cricoid cartilage is reached, the incisions are joined (ie, superior and inferior incisions), and the larynx is removed. The pharynx is then closed using an inverted running-type Connell stitch with 3-0 Vicryl over a nasogastric tube. The constrictor muscles are sutured in a similar fashion to provide for a second-layer closure.

Suturing the skin edges to the tracheal mucosa without tension forms the permanent tracheostomy. This may require defatting of the adjacent skin and/or subcutaneous tissue. Lastly, the wound is closed in layered fashion with reapproximation of platysmal, subcutaneous, and epidermal layers. If a tracheotomy was originally present in the skin flap, excision of the scarred tissue is required, and the defect is repaired as meticulously as possible. Complications include pharyngocutaneous fistula, infection, stomal stenosis, and subcutaneous hematoma.

For postoperative care, the wound drainage is monitored. Drains are discontinued when minimal drainage is noted. Wounds are covered with topical antibiotic ointment. Sutures are removed in 7-10 days. Care of the tracheostomy is as previously noted. Prior to resuming oral diet, a swallow study may be performed to exclude subclinical pharyngeal or esophageal leakage. Phonation may be restored postoperatively with minimal aspiration risks by using the Blom-Singer prosthesis via tracheoesophageal puncture.

In 1997, Krespi and Blitzer reported on 10 patients who were treated with this technique after other procedures had failed for aspiration; they noted universal success noted in all 10 patients. ^[18]

Laryngeal suspension

Suspension of the supraglottic laryngeal structures may be performed to manage hypopharyngeal collapse. Laryngeal suspension can allow for easier swallowing via a wider hypopharynx

Indications for laryngeal suspension include aspiration associated with hypopharyngeal collapse, such as that which is sometimes seen following supraglottic and/or hypopharyngectomy. Relative contraindications to laryngeal suspension include life-threatening aspiration because the benefit from this technique is modest and indicated for only a narrow spectrum of patients. It is performed most commonly in conjunction with supraglottic laryngectomy and/or hypopharyngectomy. ^{[25, 26]}

The anterior neck is prepared and draped in a sterile fashion. A horizontal skin incision at the level of the thyroid cartilage is made followed by elevation of subplatysmal flaps to the level of the thyroid cartilage and the anterior border of the mandible.

The strap muscles are identified and dissected in the midline until the thyroid cartilage is identified. The mandibular symphysis is then identified. A drill is used to bore a hole at the symphysis. A wire can be used to suspend sutures, or they may be placed directly in the hole. Three permanent sutures are passed along the superior edge of the thyroid cartilage and periosteum; 1-2 sutures are also placed at the inferior edge of the cartilage. An anterosuperior displacement of the larynx and a widening of the hypopharynx occur as the sutures are tightened. Closure of the neck is in a standard layered fashion. ^[27]

Complications include wound infection, bleeding, hematoma, and aspiration.

Following surgery, patients should be observed for aspiration; swallow studies can be performed to delineate silent aspiration. Perioperative antibiotics are commonly used.

Vocal fold medialization

This procedure is most commonly used in the setting of aspiration secondary to unilateral paralysis or atrophy of the vocal folds. Isshiki popularized the procedure in 1974, and he described an external approach via the thyroid cartilage and the placement of a subperichondrial implant to mobilize the vocal fold (thyroplasty type 1). ^[28] Bilateral vocal fold medialization can be done in a tracheotomized patient and has recently been reported to have excellent success rate in managing chronic aspiration. ^[29]

Unilateral medialization is indicated when vocal cord paralysis or atrophy is the etiology of aspiration secondary to inadequate glottic closure. Bilateral medialization is an effective option in the management of severe chronic aspiration. It allows for maintenance of a good voice, with a possible return to oral diet, but tracheostomy is required. This procedure is easily reversible if the patient's condition improves. Contraindications may include poor pulmonary reserve (ie, chronic obstructive pulmonary disease [COPD]).

The patient is placed in the supine position with the neck extended and is prepared and draped in the usual sterile fashion. During the procedure for a unilateral medialization, the patient is preferred to be under monitored sedation with local anesthesia in order to better fine tune the implant size. The incision is placed at the level of the thyroid cartilage. The incision is carried through the subcutaneous tissue, and the strap muscles are divided in the midline to the level of the thyroid cartilage.

The anterior lateral surface of the thyroid cartilage is skeletonized to the level of the perichondrium, and the height of the cartilage at the notch is measured anteriorly with calipers. The middle is marked. Windows are based 5-6 mm from the middle mark, which approximates the anterior commissure of the glottis. Males require a window of 6 X 12 mm, and females require a window of 4 X 9 mm. ^[30]

The cartilage is marked through the perichondrium (with either a Bovie needle tip or methylene blue at the 4 corners), and a posterior-based flap of perichondrium is raised. The cartilage is then incised with a No. 11 blade (or, if calcified, drilled with a diamond burr) to approximately half the width of the cartilage. The rest is elevated using a Penfield elevator to the inner perichondrium.

The inner perichondrium is not transgressed but is elevated on the inner surface if the window is removed. Alternatively, the perichondrial window may be left in place, thus requiring a smaller silastic implant. ^[31] The patient's voice is checked at various levels of medialization to determine the size of the implant by depressing the window into the larynx. The silastic implant is formed or a premade implant placed and in the sedated patient tested using fiberoptic laryngoscopy to view the larynx in addition to hearing vocal quality.

Reshaping/resizing can then be done as needed until the desired result is achieved.

The implant may be sutured in place with permanent sutures or created with a "lip" to prevent migration. The perichondrium is closed with 5-0 absorbable sutures, and a layered closure of the neck wound is performed. ^{[30, 32]}

Endoscopic approaches that involve injection of varying substances to stiffen and/or medialize the vocal fold have been described. Teflon injection was once common but now is rarely performed because of the development of Teflon granulomas, extrusion, and migration. Glycerin, collagen, and Gelfoam injections are performed but only have a temporary effect. These injections are commonly used for vocal folds in which function may be expected to return and/or as a diagnostic maneuver to predict outcome of a more permanent injection or external thyroplasty medialization procedure. Substances with more permanence include fat and hydroxyapatite.

Indications the unilateral medialization include glottic insufficiency and aspiration with unilateral vocal fold paralysis. In cases of bilateral paralysis/incompetence in a patient with ongoing aspiration complications in spite of tracheostomy, the bilateral procedure can be considered. Contraindications to this procedure include most cases with prior or active cancer of the larynx.

Complications include bleeding, infection, airway obstruction, exercise intolerance, dysphonia, ^[33] and granuloma formation. In most cases, swallowing studies are repeated before expanding a restricted diet following surgery.

Adjunctive Procedures

Cricopharyngeal myotomy

Cricopharyngeal myotomy is performed for achalasia secondary to sustained contraction of the cricopharyngeus muscle during swallowing. This is usually secondary to neurologic disorders but may be used in swallowing dysfunction after resection of supraglottic, oral, and oropharyngeal carcinoma.

Indications include cricopharyngeal achalasia in conjunction with Zenker diverticulum and oculopharyngeal muscular dystrophy. Contraindications against this as the primary procedure for aspiration include the lack of elevated manometric pressures and life-threatening aspiration.

During the procedure, the patient is positioned, with the neck prepared and draped in the usual sterile fashion. Once the patient reaches an appropriate depth of surgical general endotracheal anesthesia, an esophageal bougie or cuffed endotracheal tube is passed into the cervical esophagus. Then, via a lateral cervical approach to the skin, subcutaneous tissue and platysma are incised along the anterior border of the SCM muscle.

The trachea and the carotid sheath are identified and retracted medially and laterally, respectively. The pharynx is mobilized to reveal the posterior cricopharyngeus muscle. The muscle is incised over the previously inserted tube (if an endotracheal tube was inserted, the cuff is inflated) down to the esophageal mucosa. The neck is closed in the standard fashion with a drain.

Complications to this procedure include salivary fistula, wound infections, recurrent laryngeal nerve injuries, and vocal cord paralysis. Postoperative care includes wound drain observation for increasing drainage once feeding begins, wound care, and antibiotics.

Gastrostomy/jejunostomy

Patients who experience chronic aspiration of orally ingested material may benefit from a feeding gastrostomy or jejunostomy. They may be performed either as an open procedure or as an endoscopic procedure. These procedures allow for bypass of the upper aerodigestive system and prevent aspiration through avoidance of swallowing. They do not prevent reflux, and positioning during and after feeding is important to prevent aspiration of refluxate.

Aspiration is well documented in the presence of feeding enteral tubes and accounts for a significant degree of morbidity and mortality. In 1992, Jarnigan et al reported 15% aspiration pneumonia and 50% mortality in patients who had undergone percutaneous gastrostomy placement (PEG). ^[34] In 2000, Klodell et al reported a rate of 4% aspiration pneumonia in traumatically brain-injured patients undergoing PEG feedings. ^[35] Alimentary bypass procedures are frequently the first interventions in chronic aspiration secondary to swallow dysfunction.

Percutaneous endoscopic gastrostomy

This procedure is indicated in patients with dysphagia, chronic aspiration, and/or malnutrition with functioning gut. Jejunostomy tubes may be placed via the gastrostomy into the jejunum in cases of gastroparesis.

Contraindications include infections of the abdominal wall, nonfunctional gut, bleeding diathesis, unstable neck/cervical spine, intestinal perforation, and unstable cardiac or pulmonary conditions. For surgery, the patient is brought to the endoscopy suite and is placed under conscious sedation or general endotracheal anesthesia. An oral airway large enough for the flexible esophagoscope is inserted in the mouth. The tip of the endoscope is passed to the level of the cricopharyngeus muscle with active swallowing by the sedated patient. The endoscope is then passed to the stomach.

The abdomen is prepared and draped in a sterile fashion. The abdominal operator can see the endoscopic light shining through the abdominal wall. A left upper quadrant abdominal puncture is performed with a Seldinger-type needle technique. A wire is passed via the needle into the stomach and is grasped with a snare by the endoscopist. This wire is brought out via the mouth, and a feeding tube is advanced over it.

The feeding tube is fastened via interior and exterior flanges that hold the tube in place. Feedings may begin on the first postoperative day. ^[36]

Complications include infection of the stoma, bleeding, peritonitis, esophageal perforation, and obstruction of the tube. Patients should receive perioperative antibiotics and wound care. The caregiver should be provided with instructions on flushing and maintaining patency of the tube.

Fundoplication

Gastric reflux that has not responded to medical management and that is associated with aspiration pneumonia may benefit from fundoplication. In this procedure, a portion of the stomach is wrapped around the lower esophagus to re-create a sphincteric mechanism, thus preventing reflux. Endoscopic and open abdominal approaches are reported in the literature. Nissen described a 360° wrap. ^[37]

Indications include failure to thrive, refractory reflux, emesis, aspiration pneumonitis/pneumonia, esophageal stricture, and Barrett esophagus/esophagitis despite conservative/medical therapy. Contraindications to this procedure are an inadequate trial of medical therapy and aspiration secondary to causes other than reflux (eg, glottic incompetence, neurologic swallowing dysfunction).

During the procedure, the patient is placed in a supine position, and the abdomen is prepared and draped in a sterile fashion. A standard incision is performed, and the incision is carried through the skin, subcutaneous tissue, muscle layers, and peritoneum. The gastric fundus is identified. The vagus nerves are identified and preserved.

The gastric wrap is performed with 3 cm of the fundus encircling the intra-abdominal portion of the esophagus. Proper placement of heavy silk sutures to the seromuscular layers of the stomach, the anterior esophageal wall smooth muscle layer, and the fundus is critical to this procedure. The short gastric vessels must be identified; they can be a significant source of bleeding. These vessels may be ligated as needed to achieve a tensionless wrap. Once the wrap is in place, the wound is closed in a layered fashion. ^[38]

Complications inherent to this procedure include early satiety, esophageal obstruction, small bowel obstruction, wound infection, dehiscence, pancreatitis, inadvertent splenectomy, inability to belch, wound breakdown, and failure to control gastroesophageal reflux.

Postoperative care includes wound care and antibiotics. A nasogastric tube is used for drainage. When patients resume a solid diet, small, well-chewed food boluses are recommended.

Control of salivary output

Aspiration of salivary secretions can be a source of aspirated material. Control of salivary output has been attempted via several surgical procedures: excision of salivary glands, ductal ligation, ductal re-routing, parasympathetic nerve resection, and more recently, reduction of salivary flow has been obtained successfully by injection to the submandibular and parotid glands with botulinum toxin. ^{[39, 40]}

Ductal rerouting is not commonly used for aspiration. Increased posterior secretions in a patient who is aspirating may actually worsen both the severity and the frequency of aspiration. Salivary glands produce 1500 mL of saliva per day. ^[41] Bilateral 4-duct ligation or bilateral submandibular gland excision and parotid duct ligation eliminates most oropharyngeal secretions that lead to aspiration. Four-duct ligation is advocated as an easier and shorter procedure with equal effectiveness. Excision of the submandibular glands is advocated to minimize the possibility of increased risk of abscess formation in retained submandibular glands. Some controversy exists as to the degree of success in reducing the frequency of lower respiratory tract infections/complications of aspiration by control of salivary flow with either 4-duct ligation or bilateral submandibular gland excision. ^{[42, 43]}

Bilateral submandibular gland excision and parotid duct ligation

This procedure is indicated in patients with chronic aspiration of oropharyngeal secretions most commonly associated with cerebral palsy, epilepsy, and Down syndrome and other neuromuscular disorders. Absolute contraindications are not noted.

For surgery, the patient is placed on the operating table in the supine position, with a shoulder role. The submandibular incisions are drawn parallel and 2 finger breadths below the mandible. Paralytic agents are avoided to assist with ability to monitor marginal branch of the facial nerve.

An incision is made to the subplatysmal plane. The inferior aspect of the submandibular gland is identified and the superficial fascia over the gland is incised horizontally. In this subfacial plane, the dissection is carried superiorly, which will allow protection for the marginal branch of the facial nerve, which passes deep to the platysma and superficial to the fascia of the submandibular gland. The posterior facial vein is usually clamped and ligated and the superior end retracted, which further protects the nerve.

The anterior facial artery and vein are identified, and sometimes need to be divided. The dissection is then carried medial to the posterior facial vein and anterior to the anterior belly of the digastric muscle. The mylohyoid muscle is identified, and the attachments to the submandibular gland are dissected away from the gland.

The free edge of the mylohyoid is retracted, and the lingual nerve is identified. Dissection using a blunt dissector below the lingual nerve identifies the hypoglossal nerve and the Wharton duct. The parasympathetic ganglion is identified along the lingual nerve, and fibers to the gland at the submandibular ganglion are divided. The duct is divided and ligated close to the floor of the mouth. All further attachments are released from the gland. The opposite side is done in a similar fashion and the neck wounds are closed in layers, as previously described. ^[44]

Parotid duct ligation is then undertaken. The mouth is opened with a Jennings or dental gag. The opening of the parotid duct is identified opposite the maxillary second molar. The duct is probed with nasolacrimal probes and the area infiltrated with local anesthetic with epinephrine. An elliptical incision is made around the duct, which is then dissected out for approximately 1cm, ligated, and divided. The stump is buried and the wound is closed with chromic suture. ^[38] The opposite side is addressed in a similar fashion.

Ensuing complications include marginal mandibular nerve injuries with resultant lower lip paralysis, wound infection, lingual and hypoglossal nerve injuries, and salivary fistulas. Chronic parotitis and/or submandibular sialadenitis may occur with duct ligation procedures.

Postoperative care includes wound care and perioperative antibiotics are usually used. Drains are often used and removed once drainage is minimal.

A study by Noonan et al indicated that gland excision/duct ligation surgery can decrease the rate of hospital admissions for lower respiratory tract infections in neurologically impaired children suffering from sialorrhea and chronic salivary aspiration. The study involved 12 patients (aged 3-21 years) with congenital disorders, acquired brain injury, or, in most cases, cerebral palsy associated with perinatal injury. All but one patient (who had a laryngotracheal separation) underwent bilateral submandibular gland excision and parotid duct ligation for chronic aspiration, with two patients subsequently having a second procedure. Over a mean 5-year follow-up period, the investigators found that the median annual hospital admission rate for lower respiratory tract infection, which had been 1.0 preoperatively, fell to 0.5 among these patients. ^[45]

Ligation of bilateral submandibular ducts and bilateral parotid ducts

This procedure is indicated in patients with chronic aspiration of oropharyngeal secretions most commonly associated with cerebral palsy, epilepsy, and Down syndrome and other neuromuscular disorders. Absolute contraindications are not noted.

For surgery, the surgeon is at the head of the bed with the patient supine and a roll under the shoulders. Dental blocks can be used to open the mouth. Local anesthesia is injected into the floor of the mouth around the submandibular duct punta and around each parotid duct orifice. Midway between the submandibular puncta and plica sublingularis, the mucosa is incised and approximately 0.5 cm of the submandibular duct skeletonized, clips or suture ligatures applied, and the mucosa closed. The parotid ducts are then ligated in a manner as noted in the paragraphs above.

If eating by mouth, patients are usually able to resume their preoperative diet within hours of the procedure. Antibiotics are not routinely used. Possible complications include suppurative sialadenitis, recannulation of the ducts, and dry mouth.

Botulinum toxin injection to submandibular and parotid glands

Local injection of botulinum toxin type A acts at the cholinergic receptors within the salivary glands to reduce the salivary secretions. The effect is temporary, usually lasting approximately 12 weeks. The procedure is usually done with ultrasound guidance to ensure that the injection is into the substance of the glands. The amount injected is approximately 20 units to each parotid gland (divided into 3 locations in the gland) and 10-20 units into each submandibular gland (divided into 2 locations in each gland). Potential complications include extravasation outside the gland tissue leading to facial paresis, airway, or swallowing dysfunction. The incidence is low and complications, like the beneficial aspects of this treatment, are transient. ^{[39, 40]}

See Surgical therapy.

See Surgical therapy.

See Surgical therapy.

See Surgical therapy.

Complications to surgical intervention for chronic aspiration are procedure specific and are outlined with each procedure.

Outcome and prognosis to surgical intervention for chronic aspiration are procedure specific and are included with each procedure.